Online Practice Test 21

Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 21 > NCLEX® Review Date/Time Submitted: July 12, 2012 at 2:45 PM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		A young woman who is contemplating pregnancy and has a diet consisting mainly of "junk food" tells the nurse, "I will begin eating right and taking multiple vitamins after I become pregnant." The best nursing response is:  Your Answer: "You must begin eating well and taking multiple vitamins as soon as you suspect that you are pregnant." Correct Answer: "You must eat well and take multiple vitamins both before and during pregnancy."
		Objective: Identify tasks characteristic of different stages of development from infancy through adolescence. Rationale: Adequate intake of fruits and vegetables and B complex vitamins, which include folic acid, is important for preventing neural tube defects, which occur during the first few weeks of pregnancy-often before the woman knows that she is pregnant. It is therefore recommended that all women of child-bearing age have diets that include 400 mcg of folic acid daily. Improving the diet later in the pregnancy may be too late. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The nurse is seeing several pregnant women at a community health clinic. Which woman is at highest risk for having a low-birth weight infant or one with birth defects, and is in need of prenatal education? Your Answer: A 25-year-old woman who smokes and drinks two beers a day
		Objective: Describe usual physical development from infancy through adolescence. Rationale: Smoking during pregnancy can cause low birth weight, stillbirths, sudden infant death syndrome, cleft palates, and cleft lips. Alcohol use increases risk of low birth weight, developmental and behavioral abnormalities, spontaneous abortion, and stillbirth. Weight gains of less than 21 pounds during pregnancy; being underweight, not overweight before pregnancy; maternal age of 16 or younger or 35 and older; and low socioeconomic status are also some risk factors. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		A new mother calls the clinic crying because her 2-day-old infant now weighs 7 pounds, 2 ounces, when he weighed 7 pounds, 8 ounces at birth. She says, "I must be doing something wrong." The best nursing response would be: Your Answer: "This is normal weight loss. The infant should be back to birth weight in 3-5 days".
		Objective: Describe usual physical development from infancy through adolescence. Rationale: Most infants will lose 5-10% of their birth weight just after birth because of fluid loss. This is normal, and the weight will be regained by one week of age. This 6-ounce weight loss represents a 5% loss and is within the normal range. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		A 6-month-old infant is brought to the clinic by an aunt who says the infant's parents are out of the country on business. The nurse notes that the infant seems healthy but withdrawn, and is below the fifth percentile for weight and height on the standard growth chart. The aunt states the infant has had a succession of undependable baby-sitters since she was born, and that the parents are always working. Based on the assessment data, the nurse forms a preliminary diagnosis of: Your Answer: Failure to thrive related to inorganic causes
		Objective: Describe usual physical development from infancy through adolescence. Rationale: Failure to thrive is a syndrome caused by an organic cause, such as disease, or inorganic cause that usually involves the parent-child relationship-specifically, lack of mothering, touch, and cuddling, as well as stimulation. The infant with failure to thrive falls below the fifth percentiles for weight and height, and often fails to develop normally. The nurse detected no underlying disease in the baby, but there was a lack of maternal-infant attachment. Infant colic is characterized by prolonged crying, and generally disappears by three months of age. Shaken-baby syndrome is characterized by subdural and retinal hemorrhages. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		Parents of a 2½-year-old child report that the child has began to have temper tantrums, and ask the nurse what they should do. Strategies that the nurse could suggest include: Your Answer: Determining the child's safety and then leaving the room when the child has a tantrum
		Objective: Trace psychosocial development according to Erikson from infancy through adolescence. Rationale: Parents of toddlers need to allow children to gain control of their emotions and need to be consistent in setting limits. Leaving the child alone after first determining the child's safety allows the child time to gain self-control. Attempting to reason with toddlers is not consistent with their level of cognitive development. Giving in to the child does not set limits, but rather allows the child to control the parents. Throwing cold water on the child undermines the child's sense of dignity and autonomy. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Decide what is the best action for client and situation.
6.		Using Snellen's E chart, the nurse assesses the visual acuity of a 5-year-old as approximately 20/60. The nurse determines that the findings at this age indicate: Your Answer: Myopic vision
		Objective: Describe usual physical development from infancy through adolescence. Rationale: Normal vision (emmetropic) for a 5-year-old is approximately 20/30. Hyperopic vision is farsightedness, or inability to focus on close objects. Visual acuity findings of 20/60 indicate myopic vision or nearsightedness, the inability to focus on far away objects. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Decide what is the best action for client and situation.
7.		A nurse needs to complete diet and exercise health assessments on preschool children. Based on the nurse's knowledge of preschool cognitive and social development, the nurse determines that the best way to obtain complete and accurate information is to: Your Answer: Interview each child together with the parents
		Objective: Explain cognitive development according to Piaget from infancy through adolescence. Rationale: Preschool-age children are able to describe what they eat and what they like, and also what exercise they participate in. However, children this age may exaggerate, and mix fact with fiction, so assistance from parents or caregivers is necessary to obtain accurate information. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		The nurse is developing a nutrition program for 7- and 8-year-old children. Based on the nurse's knowledge of health problems for this age group, an important component of the program should be:  Your Answer: Identifying foods that contribute to obesity
		Objective: Describe usual physical development from infancy through adolescence. Rationale: The most common nutritional problem among children is being overweight. All nutritional programs for school-age children should include education on foods that may cause obesity. A child this age is just beginning to learn the value of money. Vitamins may not be necessary if the child eats a well-balanced diet. Complexities of saturated versus unsaturated fats in diets are best left for later school age years. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		What are the gross and fine motor milestones for a preschooler at the age of 5? ( Select all that apply.) Your Answer: Jump rope and skip Ride a bicycle Climb playground equipment Correct Answers: Jump rope and skip Climb playground equipment
		Objective: Describe usual physical development from infancy through adolescence. Rationale: By the age of 5, the preschooler is able to jump rope and skip, climb playground equipment, ride a bicycle with training wheels, and print letters and numbers. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and understanding of growth and development principles. Objective: Describe usual physical development from infancy through adolescence. Rationale: By the age of 5, the preschooler is able to jump rope and skip, climb playground equipment, ride a bicycle with training wheels, and print letters and numbers. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and understanding of growth and development principles.
10.		A preschooler should have a physical every __________ . Your Answer: day Correct Answers: One to two years 1 to 2 years
		Objective: Describe usual physical development from infancy through adolescence. Rationale: A preschooler should have a health examination every 1 to 2 years. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge of health promotion.