E32130

A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?

• The child has a history of jaw fractures.
• The child seems frightened of their parent.
• The child rocks back and forth continually.
• The child has had no immunizations since birth.

A nurse is caring for a client who is experiencing visual hallucinations followed by impaired consciousness as a result of alcohol withdrawal. Which of the following conditions should the nurse identify as causing these manifestations?

• Autonomic dysreexia
• Sleep deprivation
• Delirium
• Synergistic effect

A nurse is teaching the parents of a toddler about strategies to manage temper tantrums. Which of the following instructions should the nurse include in the teaching?

• "Establish a structured daily routine for the child."
• "Honor the child's request if she holds her breath."
• "Place the child in her room alone until the temper tantrum ends."
• "Comfort the child during the temper tantrum."

A nurse is assessing a 12-month-old infant who is immediately postoperative following hernia repair surgery. Which of the following pain measurement tools should the nurse use to determine if the infant is experiencing pain?

• FACES
• FLACC
• COMFORT
• CRIES

Avolition, Anhedonia, and blunted effect are examples of?

• Positive Symptoms
• Negative Symptoms
• Catatonia
• Cognitive Deficits

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

• Move the client next to the nurse's station.
• Use an indirect light source and turn off the television.
• Keep the television and a soft light on during the night.
• Play soft music during the night and maintain a well-lit room.

A child is undergoing hemodialysis. The child should be monitored closely for...

• Bleeding at the access site and infection.
• Hypotension and migraines.
• Shock and hypotension.
• Infections and fluid overload.

A child, in renal failure, has hyperkalemia. The nurse plans to instruct that the child should avoid the following foods:

• Spaghetti and meat sauce, breadsticks.
• Chips, cold cuts, and canned foods.
• Hamburger on a bun, cherry gelatin.
• Carrots and green, leafy vegetables.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

• Slow the intravenous flow rate
• Continue the oxytocin drip if infusing
• Place the client in a high Fowlers position
• Administer oxygen, 8 to 10 L/min, via face mask

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. the client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take?

• Apply gloves and assess perineal area
• Initiate large-bore IV access
• Notify anesthesia provider of client's request for epidural
• Obtain fetal heart tones via Doppler