GCC 201 - 225

The mother of a child with cystic fibrosis tells the nurse that her child makes "snoring" sounds when breathing. The nurse is aware that many children with cystic fibrosis have:

• Choanal atresia
• Nasal polyps
• Septal deviations
• Enlarged adenoids

Answer explanation

Option 1: Choanal atresia

Option 2: Nasal polyps

Option 3: Septal deviations

Option 4: Enlarged adenoids

Correct Option: Option 2 – Nasal polyps

Explanation: Cystic fibrosis leads to nasal polyps due to chronic sinusitis; may require surgical removal.

Which is a familial factor that most accurately places a family at risk for child abuse and neglect?

• The child has a difficult personality.
• The family has no history of abuse.
• The family is socially isolated.
• The parent experiences tremendous stress.

Answer explanation

Option 1: The child has a difficult personality.

Option 2: The family has no history of abuse.

Option 3: The family is socially isolated.

Option 4: The parent experiences tremendous stress.

Correct Option: Option 3 – The family is socially isolated.

Explanation: Social isolation is a significant familial risk factor for abuse/neglect.

One theory commonly used in family mental health nursing is Bowen's family systems theory. The central assumption in this theory is that chronic anxiety is the underlying basis for dysfunction. The theory consists of eight interlocking concepts that address anxiety and emotional processes. This includes:

• Differentiation of self.
• Quadriceps.
• The family process system.
• The nuclear family spiritual system.

Answer explanation

Option 1: Differentiation of self.

Option 2: Quadriceps.

Option 3: The family process system.

Option 4: The nuclear family spiritual system.

Correct Option: Option 1 – Differentiation of self.

Explanation: Key concepts include differentiation of self, triangles, and emotional cutoffs.

Which of the following observations in a 4-year-old suggests the possibility of child abuse?

• The presence of "rainbow" bruises
• Sucking the thumb when going to sleep
• Crying during painful procedures
• Eagerness to talk to strangers

Answer explanation

Option 1: The presence of "rainbow" bruises

Option 2: Sucking the thumb when going to sleep

Option 3: Crying during painful procedures

Option 4: Eagerness to talk to strangers

Correct Option: Option 1 – The presence of "rainbow" bruises

Explanation: “Rainbow” bruises are in multiple stages of healing — potential sign of physical abuse.

Standard orders on the nurse's unit include an intravenous infusion of 1000 mL normal saline with 20 mEq potassium chloride to run at 100 mL per hour. In which client should this order be questioned?

• 42-year-old female diagnosed with Addison's disease.
• 56-year-old male diagnosed with hypertension.
• 32-year-old male diagnosed with abdominal cramping.
• 52-year-old female diagnosed with Graves' disease.

Answer explanation

Option 1: 42-year-old female diagnosed with Addison's disease.

Option 2: 56-year-old male diagnosed with hypertension.

Option 3: 32-year-old male diagnosed with abdominal cramping.

Option 4: 52-year-old female diagnosed with Graves' disease.

Correct Option: Option 1 – 42-year-old female diagnosed with Addison's disease.

Explanation: Addison’s disease may cause hyperkalemia — potassium infusion should be avoided.

The nurse changes a wet-to-dry dressing for a client who has a pressure ulcer with infected, necrotic tissue. The nurse knows the purpose of the wet-to-dry dressing is to:

• Prevent extensive infection.
• Reduce pain.
• Debride the wound.
• Keep the wound moist.

Answer explanation

Option 1: Prevent extensive infection.

Option 2: Reduce pain.

Option 3: Debride the wound.

Option 4: Keep the wound moist.

Correct Option: Option 3 – Debride the wound.

Explanation: Dressing adheres to necrotic tissue and debrides as it’s removed.

The nurse assesses a client who is in an arm cast. The client complains of severe pain, decreased motion and sensation, and swelling in the fingers. Which action should the nurse take first?

• Notify the physician.
• Remove the cast.
• Elevate the arm.
• Administer analgesics.

Answer explanation

Option 1: Notify the physician.

Option 2: Remove the cast.

Option 3: Elevate the arm.

Option 4: Administer analgesics.

Correct Option: Option 1 – Notify the physician.

Explanation: Signs of compartment syndrome — must be reported immediately to prevent damage.

Lipid emulsions are part of total parenteral nutrition (TPN) and partial parenteral nutrition (PPN). What do lipid emulsions supply?

• Proteins.
• Carbohydrates.
• Electrolytes.
• Fats.

Answer explanation

Option 1: Proteins.

Option 2: Carbohydrates.

Option 3: Electrolytes.

Option 4: Fats.

Correct Option: Option 4 – Fats.

Explanation: Lipids deliver calories via essential fatty acids for energy.

Which nursing diagnoses is most appropriate for the client as she completes the latent phase of labor?

• Impaired gas exchange related to hyperventilation
• Alteration in oxygen perfusion related to maternal position
• Impaired physical mobility related to fetal-monitoring equipment
• Potential fluid volume deficit related to decreased fluid intake

Answer explanation

Option 1: Impaired gas exchange related to hyperventilation

Option 2: Alteration in oxygen perfusion related to maternal position

Option 3: Impaired physical mobility related to fetal-monitoring equipment

Option 4: Potential fluid volume deficit related to decreased fluid intake

Correct Option: Option 4 – Potential fluid volume deficit related to decreased fluid intake

Explanation: Fasting during labor may lead to dehydration — fluid deficit is most likely.

A client has come to the physician's office complaining of recent constipation. The nurse takes a health history. Which statement made by the client suggests a likely cause of the constipation?

• I walk with a group of friends every day at the mall for an hour.
• My spouse died 20 years ago, but my family is very loving and supportive. They live just around the corner and come over a few times a week to visit.
• The fast food place near my home has really good food. I eat there most of the time.
• What is a laxative?

Answer explanation

of the constipation?

Option 1: I walk with a group of friends every day at the mall for an hour.

Option 2: My spouse died 20 years ago, but my family is very loving and supportive. They live just around the corner and come over a few times a week to visit.

Option 3: The fast food place near my home has really good food. I eat there most of the time.

Option 4: What is a laxative?

Correct Option: Option 3 – The fast food place near my home has really good food. I eat there most of the time.

Explanation: A diet high in refined foods and low fiber causes constipation.