Review Ati nurs 4850 non comp exam (PEDS-mental)

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Ati nurs 4850 non comp exam (PEDS-mental)

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Question 1:

During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

A. "I don't care about work anymore since I was not given a promotion" B. "I wrote a short story about a heroic woman when I was really mad at my boss." C. " I still cannot remember the scene of my husband's car accident" D. "I mentally separate myself from distractions around me when I paint on canvas. "

Answer and Explanation

Choice A:

"I don't care about work anymore since I was not given a promotion":This statement demonstrates the maladaptive use of regression. Regression involves reverting to an earlier stage of development in the face of unacceptable thoughts or impulses. In this case, the client's response to not receiving a promotion is to display a lack of interest in work, which can be seen as regressing to a less mature coping mechanism.

Choice B:

"I wrote a short story about a heroic woman when I was really mad at my boss."This statement describes the defense mechanism of sublimation rather than regression. Sublimation involves channeling unacceptable impulses or emotions into more socially acceptable activities or behaviors. In this case, the client channels their anger into writing a short story, which is a constructive and creative outlet.

Choice C:

"I still cannot remember the scene of my husband's car accident":This statement does not demonstrate regression. Instead, it suggests repression, which involves the unconscious blocking of unpleasant memories, thoughts, or feelings from conscious awareness. The client's inability to remember the scene of the accident may indicate repression as a defense mechanism.

Choice D:

"I mentally separate myself from distractions around me when I paint on canvas."This statement describes the defense mechanism of dissociation rather than regression. Dissociation involves a disconnection between a person's thoughts, identity, consciousness, or memory. In this case, the client mentally separates themselves from distractions while painting, which is a form of dissociative coping.

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Question 2:

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

A. Limit time for the client to perform activities. B. Talk the client through tasks one step at a time C. Provide an activity schedule that changes from day to day D. Rotate assignment of daily caregivers

Answer and Explanation

Choice A:

Limit time for the client to perform activities. This intervention is not appropriate for a client with Alzheimer's disease. Limiting time for activities may increase agitation and frustration in individuals with cognitive impairments. Instead, it's important to allow adequate time for tasks and provide support as needed.

Choice B:

Talk the client through tasks one step at a time. This intervention is appropriate for a client with Alzheimer's disease. Breaking tasks into manageable steps and providing clear, simple instructions can help the client better understand and complete activities. This approach reduces confusion and frustration and promotes independence to the extent possible.

Choice C:

Provide an activity schedule that changes from day to day. Consistency is key in caring for individuals with Alzheimer's disease. A changing activity schedule may lead to increased confusion and disorientation. It's important to establish a routine and maintain consistency in daily activities and schedules to provide a sense of security and familiarity for the client.

Choice D:

Rotate assignment of daily caregivers. Consistency in caregiver assignments is essential for individuals with Alzheimer's disease. Changing caregivers frequently can disrupt the client's sense of security and increase confusion and anxiety. Continuity of care helps build trust and rapport between the client and caregivers, which is beneficial for the client's overall well-being.

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Question 3:

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

A. Limit the amount of time available to interact with others. B. Manipulate and control others' behaviors. C. Decrease anxiety to a tolerable level D. Focus attention on meaningly tests

Answer and Explanation

Choice A:

Limit the amount of time available to interact with others. This statement does not align with the typical behavior of individuals with obsessive-compulsive disorder (OCD). While the client's behavior of constantly picking up after others may indirectly limit interaction time, the primary motivation behind this behavior is more likely related to managing anxiety rather than intentionally limiting social interaction.

Choice B:

Manipulate and control others' behaviors. While individuals with OCD may engage in behaviors that affect others, such as seeking reassurance or involving others in their rituals, the behavior described in the scenario does not appear to be aimed at manipulating or controlling others. Instead, it seems driven by the client's internal need to alleviate anxiety through compulsive actions.

Choice C:

Decrease anxiety to a tolerable level. This is the correct choice. People with OCD often engage in compulsive behaviors as a way to reduce distressing feelings of anxiety or discomfort. By picking up after others compulsively, the client may experience temporary relief from obsessive thoughts and the associated anxiety. However, the relief is typically short-lived and can lead to a cycle of compulsive behaviors.

Choice D:

Focus attention on meaningless tasks. While the behavior of constantly picking up after others may seem repetitive or meaningless to an observer, individuals with OCD typically attribute great significance to their compulsive actions. These behaviors are driven by the need to reduce anxiety or prevent perceived harm rather than a deliberate focus on meaningless tasks.

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Question 4:

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

A. Constant need to talk about the event. B. Increasing feelings of anger. C. Sleeping 12 hr or more each day. D. Increasing sense of attachment to others.

Answer and Explanation

Choice A:

Constant need to talk about the event. While individuals with PTSD may experience intrusive thoughts or flashbacks related to the traumatic event, a constant need to talk about the event is not universally characteristic. Some individuals with PTSD may avoid discussing the traumatic event altogether due to the distress it causes them, while others may find it helpful to talk about it in therapy or support groups.

Choice B:

Increasing feelings of anger. This is the correct choice. Feelings of anger and irritability are common symptoms of PTSD. Individuals may experience heightened levels of anger as a result of feeling violated, powerless, or betrayed by the traumatic event. Anger may be directed toward the perpetrator, oneself, or others, and it can contribute to difficulties in interpersonal relationships and daily functioning.

Choice C:

Sleeping 12 hr or more each day. While sleep disturbances are common in PTSD, they typically manifest as insomnia, nightmares, or restless sleep rather than excessive sleep. Individuals with PTSD may struggle to fall asleep, experience frequent awakenings during the night, or have nightmares related to the traumatic event. Excessive sleeping is not typically associated with PTSD.

Choice D:

Increasing sense of attachment to others. Individuals with PTSD may experience difficulties in forming or maintaining relationships due to symptoms such as emotional numbing, avoidance of reminders of the trauma, and difficulties in trusting others. While some individuals may seek support from loved ones, an increasing sense of attachment to others is not typically an expected finding in PTSD.

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Question 5:

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

A. Bizarre behavior B. Somatic delusions C. Affective flattening D. Illogicality

Answer and Explanation

Choice A:

Bizarre behavior: Bizarre behavior is typically considered a positive symptom of schizophrenia rather than a negative symptom. Positive symptoms involve the presence of abnormal behaviors or experiences that are not typically seen in healthy individuals. Bizarre behavior can include hallucinations, delusions, disorganized thinking, and grossly disorganized or catatonic behavior.

Choice B:

Somatic delusions: Somatic delusions, where the individual believes they have a medical condition or physical defect that is not present, are also considered positive symptoms of schizophrenia. Positive symptoms involve distortions or exaggerations of normal functions.

Choice C:

Affective flattening: This is the correct choice. Affective flattening, also known as blunted affect, refers to a reduction in the intensity, range, and expression of emotional responses. Individuals with schizophrenia who exhibit affective flattening may have a limited range of facial expressions, reduced vocal inflections, and a diminished ability to express emotions appropriately. Affective flattening is considered a negative symptom because it reflects a decrease or absence of normal emotional functioning.

Choice D:

Illogicality: Illogicality, or disorganized thinking, is another positive symptom of schizophrenia. It involves difficulties in organizing thoughts and expressing them coherently. Individuals with schizophrenia may exhibit illogical speech patterns, such as tangentiality (going off on tangents), loose associations (jumping from one unrelated topic to another), or thought blocking (sudden interruption of thoughts).

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Question 6:

A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

A. A story book about a child who has diabetes B. A needleless syringe and a doll C. A period of play in the playroom D. A video game

Answer and Explanation

Choice A:

A story book about a child who has diabetes. While providing information about diabetes through a storybook may be beneficial for the child's understanding of the condition, it may not directly address the distress experienced after an insulin injection. This option focuses more on education rather than immediate coping with the injection-related distress.

Choice B:

A needleless syringe and a doll. This is the correct choice. Providing a needleless syringe and a doll allows the child to engage in pretend play and role-play scenarios related to the insulin injection experience. Through play, the child can express their feelings, fears, and experiences in a safe and non-threatening environment. This type of play activity can help the child gain a sense of control, familiarity, and mastery over the situation, thereby reducing distress and anxiety associated with future injections.

Choice C:

A period of play in the playroom. While engaging in play in the playroom may offer the child opportunities for distraction and enjoyment, it may not specifically address the distress experienced after an insulin injection. The effectiveness of this option in helping the child cope with the injection-related distress may depend on the specific activities available in the playroom and the child's preferences.

Choice D:

A video game. Playing a video game may provide the child with distraction and entertainment, but it may not directly address the distress experienced after an insulin injection. Additionally, screen time may not be suitable for every child, and the therapeutic benefits of video games in this context may vary.

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Question 7:

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?

A. "You have a great deal to live for." B. "It's not unusual for depressed people to feel that way." C. "You've been feeling that your life has no meaning." D. "Why do you feel you are worthless?"

Answer and Explanation

Choice A:

"You have a great deal to live for."While this response is supportive and positive, it may not effectively address the client's feelings of worthlessness. It may come across as dismissive or invalidating of the client's emotions.

Choice B:

"It's not unusual for depressed people to feel that way."This response acknowledges the commonality of feeling worthless among individuals with depression. While it normalizes the client's experience, it doesn't directly address the client's statement or offer support.

Choice C:

"You've been feeling that your life has no meaning."This response reflects active listening and demonstrates empathy by paraphrasing the client's statement to show understanding. It acknowledges the client's feelings and opens the door for further exploration of the underlying issues contributing to their sense of worthlessness.

Choice D:

"Why do you feel you are worthless?"While this response seeks to explore the underlying reasons for the client's feelings, it may come across as confrontational or judgmental. It puts the client on the spot to justify their emotions, which could make them feel defensive or invalidated.

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Question 8:

A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client?

A. "I don't like it when you address me with that tone of voice." B. "I know you can, but are you going to read it or not?" C. "Fine. Here is the schedule, and I will expect you to be on time to your therapies." D. "We do this every day. Why are you so angry with me this morning?"

Answer and Explanation

Choice A:

"I don't like it when you address me with that tone of voice."This response addresses the client's tone but does not set appropriate boundaries or address the underlying behavior. It may also escalate conflict by focusing on the nurse's feelings rather than the client's behavior.

Choice B:

"I know you can, but are you going to read it or not?"This response confronts the client's behavior and directs them back to the task at hand. However, it could be seen as somewhat dismissive and may not effectively address the client's underlying emotions or needs.

Choice C:

"Fine. Here is the schedule, and I will expect you to be on time to your therapies."This response sets clear boundaries while also providing the client with the necessary information. It acknowledges the client's ability to read the schedule independently while emphasizing the importance of attending therapies on time.

Choice D:

"We do this every day. Why are you so angry with me this morning?"This response seeks to explore the client's feelings but may come across as confrontational or accusatory. It does not effectively address the client's behavior or provide clear direction.

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Question 9:

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium.
The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

A. Experiencing diarrhea B. Drinking green tea C. Exercising moderately D. Increasing sodium intake

Answer and Explanation

Choice A:

Lithium toxicity is a significant concern for clients taking lithium, a mood stabilizer commonly prescribed for bipolar disorder. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood, potentially leading to toxicity. Therefore, cautioning against experiencing diarrhea is essential in discharge teaching for clients prescribed lithium.

Option A is correct because it identifies a factor that can contribute to lithium toxicity. Diarrhea can lead to fluid and electrolyte imbalances, affecting lithium levels in the blood.

Choice B:

Option B, drinking green tea, is not typically associated with lithium toxicity. Green tea contains caffeine, but its consumption is not a significant risk factor for lithium toxicity.

Choice C:

Option C, exercising moderately, is generally encouraged for overall health and well-being. However, it does not directly relate to lithium toxicity unless excessive sweating leads to dehydration and electrolyte imbalances.

Choice D:

Option D, increasing sodium intake, is typically discouraged for clients taking lithium because high sodium levels can affect lithium reabsorption in the kidneys, potentially leading to increased lithium levels and toxicity. However, this option is not directly related to the question about factors causing lithium toxicity.

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Question 10:

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

A. "You are being unreasonable, and I will not call your doctor at this hour." B. "I can't call a doctor in the middle of the night unless it's an emergency C. "You must be very upset about something." D. "Go back to your room, and I'll try to get in touch with your doctor"

Answer and Explanation

Choice A:

"You are being unreasonable, and I will not call your doctor at this hour."This response may escalate the situation by invalidating the client's feelings and refusing to address their request. It fails to recognize the client's distress and could lead to increased agitation or frustration.

Choice B:

"I can't call a doctor in the middle of the night unless it's an emergency."While it's true that non-urgent matters may be deferred until regular hours, this response comes across as dismissive and may exacerbate the client's distress. It does not validate the client's feelings or offer support.

Choice C:

"You must be very upset about something."This response acknowledges the client's emotions and shows empathy. It opens the door for the client to express their concerns, allowing the nurse to assess the situation further and address any immediate needs. It also avoids dismissing the client's request outright and maintains a therapeutic relationship.

Choice D:

"Go back to your room, and I'll try to get in touch with your doctor."This response instructs the client to return to their room without addressing their emotional state or concerns. It lacks empathy and fails to engage with the client's needs effectively.

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Question 11:

A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler?

A. Separates easily from primary care giver for short periods of time B. Explains the difference between right and wrong C. Cooperates in doing simple chores D. Prints letters and numbers

Answer and Explanation

Choice A:

Separates easily from primary caregiver for short periods of time: This is the correct choice. Toddlers typically begin to demonstrate increased independence and are able to separate from their primary caregiver for short periods of time without significant distress. This developmental task reflects the toddler's growing sense of autonomy and confidence in exploring their environment.

Choice B:

Explains the difference between right and wrong: While toddlers may begin to understand simple rules and expectations, they are not yet capable of explaining the difference between right and wrong in a comprehensive or abstract manner. Moral development occurs gradually over time and is influenced by various factors, including socialization and parental guidance.

Choice C:

Cooperates in doing simple chores: Toddlers may begin to imitate or participate in simple household tasks or routines, but their level of cooperation is typically limited and may vary depending on individual temperament and developmental readiness. While involvement in chores can promote a sense of responsibility and independence, toddlers are still in the early stages of learning basic self-care skills and may require supervision and assistance.

Choice D:

Prints letters and numbers: The ability to print letters and numbers typically emerges during the preschool years, around ages 3 to 5, as part of the development of fine motor skills and early literacy. Toddlers are not developmentally ready to master the precision and coordination required for printing letters and numbers. Their focus during the toddler stage is primarily on gross motor skills, sensory exploration, and language development.

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Question 12:

A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The provider prescribes restraints. The nurse should apply which of the following types of restraints for this infant?

A. Elbow B. Jacket C. Mummy D. Wrist

Answer and Explanation

Choice A:

Elbow. Elbow restraints are typically used to limit movement of the elbow joint. However, they may not be suitable for an infant post-cleft lip and palate repair surgery. The primary concern after this type of surgery is to prevent the infant from touching the surgical site, which requires a more comprehensive restraint method.

Choice B:

Jacket. A jacket restraint wraps around the torso and arms, similar to a mummy restraint. However, jacket restraints may not provide as much immobilization or security for the infant's arms as a mummy restraint. Given the importance of preventing the infant from touching the surgical site, a mummy restraint may be more appropriate in this case.

Choice C:

Mummy. This is the correct choice. A mummy restraint wraps around the infant's torso and arms, providing secure immobilization to prevent the infant from touching the surgical site. It is specifically designed to restrict movement while still allowing some freedom for comfort and positioning. This type of restraint is commonly used for infant’s post-cleft lip and palate repair surgery to facilitate optimal healing and prevent disruption of sutures.

Choice D:

Wrist. Wrist restraints are typically used to restrict movement of the wrists and hands. However, they may not be suitable for an infant post-cleft lip and palate repair surgery, as the primary concern is to prevent the infant from touching the surgical site on the face. Wrist restraints would not effectively address this issue and may be unnecessarily restrictive for the infant's comfort and mobility.

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Question 13:

A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?

A. Administer opioids for pain. B. Apply bilateral wrist restraints C. Implement a soft diet. D. Offer fluids through a straw.

Answer and Explanation

Choice A:

Administer opioids for pain:While pain management is crucial after surgery, opioids may not be the first-line choice for pain relief in toddlers due to their potential side effects, including respiratory depression and sedation. Non-opioid pain relief methods such as acetaminophen or ibuprofen may be preferred, depending on the toddler's age and the surgeon's preference.

Choice B:

Apply bilateral wrist restraints:After a cleft palate repair, it's essential to prevent the toddler from putting hands or objects into their mouth, as this could disrupt the surgical site and compromise healing. Bilateral wrist restraints help to immobilize the toddler's arms and prevent them from reaching the mouth area, reducing the risk of injury and promoting healing.

Choice C:

Implement a soft diet:A soft diet may be appropriate for the toddler once they have fully recovered from the surgery and the surgical site has healed adequately. However, 24 hours postoperative is too soon to introduce a soft diet, as the toddler may still be recovering from anesthesia and experiencing discomfort. It's essential to follow the surgeon's orders regarding diet progression.

Choice D:

Offer fluids through a straw:Offering fluids through a straw may pose a risk of aspiration or injury to the surgical site, especially in the immediate postoperative period. It's crucial to follow the surgeon's instructions regarding feeding methods and avoid using straws until the toddler has fully recovered and the surgical site has healed.

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Question 14:

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.)

A. The preschooler speaks in three-word sentences. B. The preschooler talks to himself when reading. C. The preschooler speaks in a nasally tone. D. The preschooler stutters when speaking. E. The preschooler mispronounces words.

Answer and Explanation

Choice A:

The preschooler speaks in three-word sentences. Speaking in three-word sentences is a normal developmental milestone for preschoolers. It demonstrates the child's ability to form simple sentences and communicate basic ideas. While further language development may be encouraged, it alone does not indicate a need for speech therapy.

Choice B:

The preschooler talks to himself when reading. Talking to oneself while reading is a common behavior among preschoolers and is not necessarily indicative of a speech disorder. It may reflect the child's engagement with the material or their process of learning and understanding language. This behavior alone does not warrant speech therapy.

Choice C:

The preschooler speaks in a nasally tone. A nasally tone of speech can indicate issues with resonance or airflow through the nasal passages, which may be caused by anatomical abnormalities or muscle weakness. This finding suggests a need for speech therapy to address resonance issues and improve speech clarity.

Choice D:

The preschooler stutters when speaking. Stuttering involves disruptions in the flow of speech, characterized by repetitions, prolongations, or blocks of sounds, syllables, or words. Persistent stuttering beyond the preschool years may require intervention from a speech therapist to improve fluency and communication skills.

Choice E:

The preschooler mispronounces words. Mispronunciations of words are common during early language development, but persistent or severe mispronunciations may indicate phonological or articulation disorders that could benefit from speech therapy intervention. Addressing these issues early can help improve the child's intelligibility and overall communication skills.

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Question 15:

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply).

A. Spinning a toy repetitively B. Consistent limit testing C. Ritualistic behavior D. Short attention span E. Delayed language development

Answer and Explanation

Choice A:

Spinning a toy repetitively: Repetitive behaviors, such as spinning objects or repetitive movements, are common in children with ASD. These behaviors often serve as self-stimulatory or soothing activities and may be used as a way to cope with sensory stimulation or to seek sensory input.

Choice B:

Consistent limit testing: While limit testing can occur in children with ASD, it is not a specific hallmark of the disorder. Limit testing is more commonly associated with typical developmental behavior or oppositional defiant disorder rather than ASD.

Choice C:

Ritualistic behavior: Children with ASD often engage in ritualistic or repetitive behaviors, such as adhering to strict routines or rituals, having specific preferences for how objects are arranged, or engaging in repetitive movements or actions. These behaviors can provide a sense of predictability and control in their environment.

Choice D:

Short attention span: Many children with ASD have difficulty sustaining attention and may exhibit a short attention span, particularly in tasks that do not align with their specific interests or preferences. However, attention span can vary widely among children with ASD, and some may have exceptional focus on particular activities or topics of interest.

Choice E:

Delayed language development: Delayed language development is a common characteristic of ASD. Some children with ASD may experience delays in acquiring spoken language skills, exhibit echolalia (repetition of words or phrases), or have difficulty with expressive and receptive language. However, it's important to note that language development can vary significantly among individuals with ASD, and some may have average or even advanced language skills.

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Question 16:

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture. Which one of the following should the nurse include in the plan of care?

A. Place the infant in an infant seat for 2 hr following the procedure. B. Hold the infant's chin to his chest and knees to his abdomen during the procedure. C. Keep the infant NPO for 6 hr prior the procedure. D. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure

Answer and Explanation

Choice A:

Place the infant in an infant seat for 2 hours following the procedure. There is no specific need to place the infant in an infant seat for 2 hours following a lumbar puncture. After the procedure, the infant should be positioned comfortably and safely, but there is no requirement for a specific duration in an infant seat.

Choice B:

Hold the infant's chin to his chest and knees to his abdomen during the procedure. This positioning is not appropriate for a lumbar puncture. The correct positioning for a lumbar puncture involves having the infant in a lateral recumbent (side-lying) position with knees flexed up toward the chest, allowing the spine to be flexed and creating space between the vertebrae for the needle insertion.

Choice C:

Keep the infant NPO for 6 hours prior to the procedure. Keeping the infant NPO (nothing by mouth) for 6 hours prior to the procedure is not necessary for a lumbar puncture. Infants can continue breastfeeding or formula feeding as usual before the procedure. However, if sedation or anesthesia is planned for the procedure, specific fasting guidelines may apply depending on institutional protocols and the infant's age and health status.

Choice D:

Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 minutes prior to the procedure. This is the correct choice. Applying a eutectic mixture of lidocaine and prilocaine cream topically before the procedure helps to numb the skin and reduce pain at the site of the lumbar puncture. It is a standard practice to minimize discomfort for the infant during the procedure.

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Question 17:

A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply)

A. Dental care B. How to encourage cooperative play C. Need for increased caloric intake D. Management of tantrums E. How to establish trust

Answer and Explanation

Choice A:

Dental care: Teaching parents about dental care for toddlers is important for promoting good oral hygiene habits and preventing dental issues such as cavities. This may include guidance on toothbrushing techniques, appropriate fluoride toothpaste use, regular dental check-ups, and avoidance of sugary foods and drinks.

Choice B:

How to encourage cooperative play: Encouraging cooperative play is an important aspect of a toddler's social and emotional development. This topic may be more relevant for preschool-aged children rather than toddlers, who are typically more focused on parallel play.

Choice C:

Need for increased caloric intake: Toddlers generally have high energy needs due to their rapid growth and development. However, this information may not be necessary in health promotion teaching for parents of toddlers unless there are specific concerns about the child's growth or nutritional status. It's essential to focus on providing a balanced diet rather than emphasizing the need for increased caloric intake.

Choice D:

Management of tantrums: Tantrums are common during the toddler years as children begin to assert their independence and struggle with emotions and self-regulation. Teaching parents strategies for managing tantrums, such as remaining calm, setting limits, providing distraction, and offering positive reinforcement for appropriate behavior, can be helpful in promoting positive behavior management and reducing stress for both the child and the parents.

Choice E:

How to establish trust: Establishing trust is a fundamental aspect of parent-child relationships and contributes to the child's sense of security and attachment. While this is an important topic, it may be more relevant for infancy rather than toddlerhood. However, reinforcing the importance of responsive caregiving, consistent routines, and nurturing interactions can still support the development of trust during the toddler years.

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Question 18:

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane??

A. Before auscultating the chest and abdomen B. Before examining the head and neck C. At the end D. At the beginning

Answer and Explanation

Choice A:

Before auscultating the chest and abdomen: Examining the tympanic membrane before auscultating the chest and abdomen is not ideal. It's important to follow a systematic approach in physical examination, typically starting with less invasive assessments before progressing to more invasive or uncomfortable ones. Therefore, examining the tympanic membrane before auscultating the chest and abdomen may disrupt this systematic approach.

Choice B:

Before examining the head and neck: Similarly, examining the tympanic membrane before examining the head and neck is not appropriate. The head and neck examination typically includes less invasive assessments such as observing the child's appearance, palpating the fontanelles, and inspecting the scalp, face, and neck. The tympanic membrane examination, which involves using an otoscope, is more invasive and should be performed later in the examination.

Choice C:

At the end: This is the correct choice. Examining the tympanic membrane at the end of the physical examination allows the nurse to establish rapport with the child and gain their cooperation before performing a potentially uncomfortable or intrusive examination of the ears. Starting with less invasive and more familiar assessments, such as observing the child's general appearance and behavior, auscultating the chest and abdomen, and examining the head and neck, can help build trust and reduce anxiety before proceeding to more specific assessments, such as otoscopy.

Choice D:

At the beginning: Examining the tympanic membrane at the beginning of the physical examination may cause the child distress and anxiety, potentially making the rest of the examination more challenging. It's preferable to perform less invasive assessments first to help the child become more comfortable and cooperative before proceeding to more invasive examinations like otoscopy. Therefore, examining the tympanic membrane at the beginning is not recommended.

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Question 19:

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?

A. Decreased auditory and visual acuity B. Decreased display of emotions C. Forgetfulness gradually progressing to disorientation D. Personality traits that are opposite of original traits

Answer and Explanation

Choice A:

Decreased auditory and visual acuity: Decreased auditory and visual acuity are not typically associated with primary dementia. While sensory impairments may occur with aging, they are not direct manifestations of dementia.

Choice B:

Decreased display of emotions: While individuals with dementia may experience changes in emotional expression, such as mood swings or emotional lability, a decreased display of emotions is not a universal manifestation. Some individuals may exhibit heightened emotional responses or become more emotionally labile as the disease progresses.

Choice C:

Forgetfulness gradually progressing to disorientation: This is the correct choice. Forgetfulness is often one of the initial signs of dementia, and it typically progresses to more severe cognitive impairments, including disorientation to time, place, and person. As dementia advances, individuals may become increasingly confused about their surroundings and lose track of time and events.

Choice D:

Personality traits that are opposite of original traits: While some changes in personality and behavior may occur in individuals with dementia, such as agitation, irritability, or apathy, personality traits that are opposite of the original traits are not necessarily characteristic of primary dementia. Personality changes in dementia are often more related to cognitive decline and impairment rather than a complete reversal of personality traits.

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Question 20:

A parent tells a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk for which of the following disorders?

A. Rickets B. Iron deficiency anemia C. Obesity D. Diabetes mellitus

Answer and Explanation

Choice A:

Rickets: Rickets is a condition caused by a deficiency of vitamin D, calcium, or phosphate, leading to softening and weakening of the bones. While milk is a good source of vitamin D and calcium, excessive consumption of milk alone may not necessarily lead to rickets unless the child has inadequate exposure to sunlight or a diet lacking in other essential nutrients.

Choice B:

Iron deficiency anemia: This is the correct choice. Excessive consumption of milk, particularly if it replaces solid foods in the diet, can lead to iron deficiency anemia in toddlers. Cow's milk is low in iron and can inhibit iron absorption from other foods, leading to iron deficiency over time. Iron deficiency anemia can result in fatigue, weakness, developmental delays, and impaired cognitive function in young children.

Choice C:

Obesity: While excessive milk consumption can contribute to excessive calorie intake, leading to weight gain and potentially obesity, the scenario describes a toddler with a poor appetite for solid foods. Therefore, the primary concern in this case is not obesity but rather the risk of nutritional deficiencies, particularly iron deficiency anemia.

Choice D:

Diabetes mellitus: Excessive milk consumption alone is not a direct risk factor for diabetes mellitus in toddlers. However, a diet high in refined sugars and excessive calorie intake, including from milk, can contribute to the development of obesity and insulin resistance, increasing the risk of type 2 diabetes mellitus later in life. However, the primary concern in this scenario is the risk of nutritional deficiencies, particularly iron deficiency anemia, rather than diabetes mellitus.

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Question 21:

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

A. "Why are you feeling so down?" B. "I understand. I've felt like that before, too" C. "I’ll just sit here with you for a few minutes then." D. "It might help you feel better if you talk about it"

Answer and Explanation

Choice A:

"Why are you feeling so down?": This response may come across as intrusive and may not be well-received by the client. It puts pressure on the client to provide an explanation for their feelings, which they may not be ready or willing to do at that moment.

Choice B:

"I understand. I've felt like that before, too": While expressing empathy can be helpful, it's important for the nurse to validate the client's current feelings without making assumptions about their own experiences. This response could inadvertently shift the focus away from the client's feelings and onto the nurse's experiences.

Choice C:

"I’ll just sit here with you for a few minutes then.": This is the best response as it acknowledges the client's feelings, respects their desire for solitude, and offers the nurse's presence as a source of support without pressure to talk. Simply being present with the client demonstrates empathy and provides comfort during a difficult time.

Choice D:

"It might help you feel better if you talk about it": While encouraging the client to talk about their feelings can be beneficial in some situations, it's essential to respect the client's autonomy and readiness to engage in conversation. In this case, the client has expressed a desire not to talk, so offering unsolicited advice to talk may feel dismissive of their feelings.

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Question 22:

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

A. Plan the client's schedule to allow time for rituals. B. Isolate the client for a period of time. C. Confront the client about the senseless nature of the repetitive behaviors D. Set strict limits on the behaviors so that the client can conform to the un, rules and schedules

Answer and Explanation

Choice A:

Plan the client's schedule to allow time for rituals: This is the most appropriate action. It is essential to recognize that compulsive behaviors in OCD serve as coping mechanisms for the individual. Allowing time for rituals within the client's schedule can help reduce anxiety and provide a sense of control. Gradual exposure and response prevention techniques can be incorporated into the treatment plan over time to help the client gradually decrease reliance on rituals.

Choice B:

Isolate the client for a period of time: Isolating the client may exacerbate feelings of anxiety and distress, as well as decrease opportunities for social interaction and support, which are essential components of mental health treatment.

Choice C:

Confront the client about the senseless nature of the repetitive behaviors: Confrontation may lead to defensiveness and resistance from the client. It is important to approach the client with empathy and understanding rather than judgment. Educating the client about the nature of OCD and the role of compulsive behaviors in managing anxiety can be more helpful in fostering insight and motivation for change.

Choice D:

Set strict limits on the behaviors so that the client can conform to the unit rules and schedules: Setting strict limits may increase the client's distress and resistance. It is important to collaborate with the client in treatment planning and find a balance between supporting the client's needs and maintaining a therapeutic environment. Gradual exposure and response prevention techniques should be implemented in a supportive manner rather than through strict enforcement.

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Question 23:

A nurse is caring for an 11-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions?

A. Developing autonomy B. Regression C. Resentment toward the mother D. An anxiety reaction

Answer and Explanation

Choice A:

Developing autonomy:Rationale: Developing autonomy typically involves a toddler's exploration of their environment and assertion of independence. While seeking comfort in familiar behaviors like thumb-sucking can be a part of autonomy development, the behavior described in the scenario is more indicative of regression, which involves returning to earlier, more infantile behaviors rather than progressing towards independence.

Choice B:

Regression:Rationale: Regression refers to reverting to behaviors characteristic of an earlier stage of development. In this scenario, the toddler's behavior of sitting quietly in the corner of the crib and sucking her thumb, as well as turning away from the nurse, suggests a regression to earlier comforting behaviors that are typical of younger infants. This regression may be a response to the stress and anxiety of being hospitalized and separated from the mother, seeking comfort in familiar behaviors.

Choice C:

Resentment toward the mother:Rationale: There is no evidence in the scenario to suggest resentment toward the mother. The toddler's behavior of seeking comfort in thumb-sucking and turning away from the nurse is more indicative of distress or regression in response to the hospitalization and separation from the mother rather than directed resentment toward her.

Choice D:

An anxiety reaction:Rationale: The toddler's behavior of sitting quietly in the corner of the crib, sucking her thumb, and turning away from the nurse suggests a response to stress or anxiety rather than an anxiety reaction per se. While anxiety may be a component of the toddler's emotional state, the behavior aligns more closely with regression as a coping mechanism in response to the stressors of hospitalization and separation from the mother.

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Question 24:

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary Intervention?

A. Providing support for family and friends following a suicide B. Recognizing the warning signs of suicide C. Performing life-saving measures following a suicide attempt D. Identifying individuals who are at higher risk for attempting suicide

Answer and Explanation

Choice A:

Providing support for family and friends following a suicide:Providing support for family and friends following a suicide is an example of a tertiary intervention. Tertiary interventions focus on providing support, counseling, and resources to individuals affected by suicide after the event has occurred, aiming to prevent further emotional distress, promote healing, and reduce the risk of additional suicides in the community.

Choice B:

Recognizing the warning signs of suicide:Recognizing the warning signs of suicide is an example of a primary intervention. Primary interventions aim to prevent suicide by identifying individuals at risk and intervening before a suicide attempt occurs. Educating healthcare professionals and the community about the warning signs of suicide is crucial for early identification and intervention.

Choice C:

Performing life-saving measures following a suicide attempt:This is an example of a secondary intervention. Secondary interventions involve actions taken after the occurrence of a suicide attempt or completed suicide to prevent further harm or loss of life. Performing life-saving measures, such as cardiopulmonary resuscitation (CPR) or providing emergency medical care, falls under secondary interventions because it occurs after the suicide attempt to mitigate the immediate physical consequences.

Choice D:

Identifying individuals who are at higher risk for attempting suicide:Identifying individuals who are at higher risk for attempting suicide is also an example of a primary intervention. This involves screening, assessment, and risk evaluation to identify individuals with risk factors and warning signs of suicide, allowing for targeted interventions, support, and prevention strategies to be implemented before a suicide attempt occurs.

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Question 25:

A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching?

A. Launder the child's clothing with fabric softener. B. Dress the child in woolen clothes during cold months. C. Give the child a bubble baths every day. D. Apply a topical corticosteroid ointment to the affected area

Answer and Explanation

Choice A:

Launder the child's clothing with fabric softener: Fabric softeners can contain chemicals and fragrances that may irritate the skin of a child with eczema. It's advisable to wash the child's clothing with a mild, fragrance-free detergent and avoid the use of fabric softeners.

Choice B:

Dress the child in woolen clothes during cold months: Wool can be irritating to sensitive skin and may exacerbate eczema symptoms. It's best to dress the child in soft, breathable fabrics such as cotton to minimize irritation.

Choice C:

Give the child bubble baths every day: Bubble baths can strip the skin of its natural oils and exacerbate eczema symptoms. It's recommended to limit baths to every other day or less frequently and to use lukewarm water without added bubbles or harsh soaps.

Choice D:

Apply a topical corticosteroid ointment to the affected area: This is the correct choice. Topical corticosteroids are commonly used to reduce inflammation and relieve itching associated with eczema. They help to control eczema flare-ups and manage symptoms effectively. However, it's important to follow the healthcare provider's instructions regarding the frequency and duration of corticosteroid use and to apply them only to the affected areas of the skin.

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Ati nurs 4850 non comp exam (PEDS-mental)

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