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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

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.

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.

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

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.

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.

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.

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

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

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

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?