nursing nclex quiz answer and rationale part III


Topics included in this exam are questions about pediatric nursing, diabetes, lithium, and diseases common to children.


1. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
A. Chronic vessel plaque formation
B. Pulmonary embolism
C. Occlusions at the vessel bifurcations
D. Coronary artery aneurysms

2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
A. “I cannot give this medication as it is written. I have no idea of what you mean.”
B. “Would you please clarify what you have written so I am sure I am reading it correctly?”
C. “I am having difficulty reading your handwriting. It would save me time if you would be more careful.”
D. “Please print in the future so I do not have to spend extra time attempting to read your writing.”

3. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
A. Reprimand the child and give a 15-minute “time out”
B. Maintain a permissive attitude for this behavior
C. Use patience and a sense of humor to deal with this behavior
D. Assert authority over the child through limit setting

4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A. “Have you had a recent heart attack?”
B. “Do you become short of breath during your normal daily activities?”
C. “How many pillows do you use at night to sleep comfortably?”
D. “Do you smoke?”

5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
A. Fluid restriction 1000cc per day
B. Ambulate in hallway 4 times a day
C. Administer analgesic therapy as ordered
D. Encourage increased caloric intake

6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
A. Sexual promiscuity
B. Poor body image
C. Dropping out of school
D. Drug experimentation

7. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
A. Pre-interaction
B. Orientation
C. Working
D. Termination

8. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to
A. Begin mouth to mouth resuscitation
B. Give the child water to help in swallowing
C. Perform 5 abdominal thrusts
D. Call for the emergency response team

9. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?
A. “Do not worry. Epilepsy can be treated with medications.”
B. “The seizure may or may not mean your child has epilepsy.”
C. “Since this was the first convulsion, it may not happen again.”
D. “Long-term treatment will prevent future seizures.”

10. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
A. Gestational age assessment suggested growth retardation
B. Meconium was cleared from the airway at delivery
C. Phototherapy was used to treat Rh incompatibility
D. The infant received mechanical ventilation for 2 weeks

11. Parents of a 6 month-old breastfed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first?
A. Cereal
B. Eggs
C. Meat
D. Juice

12. A victim of domestic violence states, “If I were better, I would not have been beaten.” Which feeling best describes what the victim may be experiencing?
A. Fear
B. Helplessness
C. Self-blame
D. Rejection

13. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client’s recent memory?
A. “Name the year.” “What season is this?” (pause for answer after each question)
B. “Subtract 7 from 100 and then subtract 7 from that.” (pause for answer) “Now continue to subtract 7 from the new number.”
C. “I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.”
D. “What is this on my wrist?” (point to your watch) Then ask, “What is the purpose of it?”

14. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
A. Venturi mask
B. Partial rebreather mask
C. Non-rebreather mask
D. Simple face mask

15. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?
A. Capillary refill of fingers on right hand is 3 seconds
B. Skin warm to touch and normally colored
C. Client reports prickling sensation in the right hand
D. Slight swelling of fingers of right hand

16. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
A. Liver function
B. Kidney function
C. Blood sugar
D. Cardiac enzymes

17. Which client is at highest risk of developing a pressure ulcer?
A. 23-year-old in traction for fractured femur
B. 72-year-old with peripheral vascular disease, who is unable to walk without assistance
C. 75-year-old with left-sided paresthesia and is incontinent of urine and stool
D. 30-year-old who is comatose following a ruptured aneurysm

18. Which contraindication should the nurse assess for prior to giving a child immunization?
A. Mild cold symptoms
B. Chronic asthma
C. Depressed immune system
D. Allergy to eggs

19. The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
A. Neurotoxicity
B. Hepatomegaly
C. Nephrotoxicity
D. Ototoxicity

20. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
A. Protect the eyes of the neonate from the heat lamp
B. Monitor the neonate’s temperature
C. Warm all medications and liquids before giving
D. Avoid touching the neonate with cold hands

21. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
A. “I give my insulin to myself in my thighs.”
B. “Sometimes when I put my shoes on I don’t know where my toes are.”
C. “Here are my up and down glucose readings that I wrote on my calendar.”
D. “If I bathe more than once a week my skin feels too dry.”

22. A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
A. Place the child in the nearest bed
B. Administer IV medication to slow down the seizure
C. Place a padded tongue blade in the child’s mouth
D. Remove the child’s toys from the immediate area

23. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?
A. “I usually avoid driving at night since lights sometimes seem to make things blur.”
B. “I take half of the usual dose for my sinuses to maintain my blood pressure.”
C. “I have to sit at the side of the pool with the grandchildren since I can’t swim with this eye problem.”
D. “I take extra fiber and drink lots of water to avoid getting constipated.”

24. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
A. Irritability
B. Slight edema at site
C. Local tenderness
D. Temperature of 102.5 F

25. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering
A. Pulmonary embolectomy
B. Vena caval interruption
C. Increasing the coumadin therapy to an INR of 3-4
D. Thrombolytic therapy

26. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
A. Drink small amounts of liquids frequently
B. Eat the evening meal just before retiring
C. Take sodium bicarbonate after each meal
D. Sleep with head propped on several pillows

27. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
A. “I’m going to try feeding my baby some rice cereal.”
B. “When he wakes at night for a bottle, I feed him.”
C. “I dip his pacifier in honey so he’ll take it.”
D. “I keep formula in the refrigerator for 24 hours.”

28. For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
A. Institute seizure precautions
B. Weigh the child twice per shift
C. Encourage the child to eat protein-rich foods
D. Relieve boredom through physical activity

29. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
A. “This action of my lips helps to keep my airway open.”
B. “I can expel more when I pucker up my lips to breathe out.”
C. “My mouth doesn’t get as dry when I breathe with pursed lips.”
D. “By prolonging breathing out with pursed lips the little areas in my lungs don’t collapse.”

30. A 57-year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
A. Ask the client if he has noticed any bleeding or dark stools
B. Tell the client to call 911 and go to the emergency department immediately
C. Schedule a repeat Hemoglobin and Hematocrit in 1 month
D. Tell the client to schedule an appointment with a hematologist

31. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?
A. “Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior.”
B. “What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?”
C. “Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.”
D. “You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done.”

32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
A. Review the client’s weight pattern over the year
B. Ask the mother to record her diet for the last 24 hours
C. Encourage her to talk about her view of herself
D. Give her several pamphlets on postpartum nutrition

33. Which of the following measures would be appropriate for the nurse to teach the parent of a nine-month-old infant about diaper dermatitis?
A. Use only cloth diapers that are rinsed with bleach
B. Do not use occlusive ointments on the rash
C. Use commercial baby wipes with each diaper change
D. Discontinue a new food that was added to the infant’s diet just prior to the rash

34. A 16-year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause of suicide in adolescents is
A. Progressive failure to adapt
B. Feelings of anger or hostility
C. Reunion wish or fantasy
D. Feelings of alienation or isolation

35. A mother brings her 26-month-old to the well-child clinic. She expresses frustration and anger due to her child’s constantly saying “no” and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
A. Trust
B. Initiative
C. Independence
D. Self-esteem

36. Following mitral valve replacement surgery, a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute?
A. 60 microdrops/minute
B. 20 microdrops/minute
C. 30 microdrops/minute
D. 40 microdrops/minute

37. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
A. Norplant is safe and may be removed easily
B. Oral contraceptives should not be used by smokers
C. Depo-Provera is convenient with few side effects
D. The IUD gives protection from pregnancy and infection

38. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A. Confusion
B. Loss of half of visual field
C. Shallow respirations
D. Tonic-clonic seizures

39. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?
A. “Nursing will help contract the uterus and reduce your risk of bleeding.”
B. “Breastfeeding twins will take too much energy after the hemorrhage.”
C. “The blood transfusion may increase the risks to you and the babies.”
D. “Lactation should be delayed until the “real milk” is secreted.”

40. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?
A. These side effects are common and should subside in a few days
B. The client is probably having an allergic reaction and should discontinue the drug
C. Taking the lithium on an empty stomach should decrease these symptoms
D. Decreasing dietary intake of sodium and fluids should minimize the side effects

41. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
A. Place pillows under the knees
B. Use elastic stockings continuously
C. Encourage range of motion and ambulation
D. Massage the legs twice daily

42. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that
A. Circumcision is delayed so the foreskin can be used for the surgical repair
B. This procedure is contraindicated because of the permanent defect
C. There is no medical indication for performing a circumcision on any child
D. The procedure should be performed as soon as the infant is stable

43. The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
A. Loss of consciousness
B. Feeding problems
C. Poor weight gain
D. Fatigue with crying

44. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?
A. Double the birth weight
B. Triple the birth weight
C. Gain 6 ounces each week
D. Add 2 pounds each month

45. The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
A. Raise the head of the bed at least 30 degrees
B. Encourage ambulation within 24 hours
C. Maintain in a flat position, logrolling as needed
D. Encourage leg contraction and relaxation after 48 hours

46. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
A. “Focus on your son’s’ needs during the first days at home.”
B. “Tell each child what he can do to help with the baby.”
C. “Suggest that your husband spend more time with the boys.”
D. “Ask the children what they would like to do for the newborn.”

47. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
A. A cerebral vascular accident
B. Postoperative meningitis
C. Medication reaction
D. Metabolic alkalosis

48. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when “his eyes rolled upward.” The nurse recognizes this as what type of side effect?
A. Oculogyric crisis
B. Tardive dyskinesia
C. Nystagmus
D. Dysphagia

49. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
A. A social worker from the local hospital
B. An occupational therapist from the community center
C. A physical therapist from the rehabilitation agency
D. Another client with diabetes mellitus and takes insulin

50. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
A. Convince the client that the hospital staff is trying to help
B. Help the client to enter into group recreational activities
C. Provide interactions to help the client learn to trust staff
D. Arrange the environment to limit the client’s contact with other clients

Answers & Rationale

1. Answer: D: Coronary artery aneurysms. Kawasaki Disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms.

2. Answer: B: “Would you please clarify what you have written so I am sure I am reading it correctly?” Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.

3. Answer: C. Use patience and a sense of humor to deal with this behavior.The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.

4. Answer: B. “Do you become short of breath during your normal daily activities?”These are the symptoms of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess both associated with right-sided heart failure.

5. Answer: C. Administer analgesic therapy as ordered.The main general objectives in the treatment of a sickle cell crisis is bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement and antibiotics to treat any existing infection.

6. Answer: B. Poor body image. As the adolescent gains weight, there is a lessening sense of self-esteem and poor body image.

7. Answer: C. Working.During the working phase, alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior.

8. Answer: C. Perform 5 abdominal thrusts.At this age, the most effective way to clear the airway of food is to perform abdominal thrusts.

9. Answer: B. “The seizure may or may not mean your child has epilepsy.”There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown).

10. Answer: D. The infant received mechanical ventilation for 2 weeks.Bronchopulmonary dysplasia is an iatrogenic disease caused by therapies such as use of positive-pressure ventilation used to treat lung disease.

11. Answer: A. Cereal.The guidelines of the American Academy of Pediatrics recommend that one new food be introduced at a time, beginning with strained cereal.

12. Answer: C. Self-blame.Domestic violence victims may be immobilized by a variety of affective responses, one being self-blame. The victim believes that a change in their behavior will cause the abuser to become nonviolent, which is a myth.
13. Answer: C. “I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.”

14. Answer: C. Non-rebreather mask.The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of oxygen is available.

15. Answer: C. Client reports prickling sensation in the right hand .Prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

16. Answer: A. Liver function.INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

17. Answer: C. 75-year-old with left-sided paresthesia and is incontinent of urine and stool.Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

18. Answer: C. Depressed immune system .Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.

19. Answer: C. Nephrotoxicity.Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

20. Answer: B. Monitor the neonate’s temperature.When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations.
Option A: The use of heat lamps is not safe as there is no way to regulate their temperature.
Option C: Warming medications and fluids is not indicated.
Option D: While touching with cold hands can startle the infant it does not pose a safety risk.

21. Answer: B. “Sometimes when I put my shoes on I don’t know where my toes are.”Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients do not feel pressure and/or pain and are at high risk for skin impairment.

22. Answer: D. Remove the child’s toys from the immediate area.Nursing care for a child having a seizure includes maintaining airway patency, ensuring safety, administering medications, and providing emotional support.
Options A and C: Since the seizure has already started, nothing should be forced into the child”s mouth and they should not be moved. Of the choices given, first priority would be for safety.

23. Answer: D. “I take extra fiber and drink lots of water to avoid getting constipated.” Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.

24. Answer: D. Temperature of 102.5 F.An adverse reaction of a fever should be reported immediately. Other reactions that should be reported include crying for > 3 hours, seizure activity, and tender, swollen, reddened areas.

25. Answer: B. Vena caval interruption. Clients with contraindications to heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.

26. Answer: D. Sleep with head propped on several pillows.Heartburn is a burning sensation caused by regurgitation of gastric contents that is best relieved by sleeping position, eating small meals, and not eating before bedtime.

27. Answer: C. “I dip his pacifier in honey so he’ll take it.”Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.

28. Answer: A. Institute seizure precautions.The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications and anticipatory preparation such as seizure precautions are needed.

29. Answer: D. “By prolonging breathing out with pursed lips my little areas in my lungs don’t collapse.”Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of the weak alveolar walls from the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing. This is the major reason to use it.
Options A, B, and C: The other options are secondary effects of pursed-lip breathing.

30. Answer: A. Ask the client if he has noticed any bleeding or dark stools.Normal hemoglobin for males is 13.0 – 18 g/100 ml. Normal hematocrit for males is 42 – 52%. These values are below normal and indicate mild anemia. The first thing the nurse should do is ask the client if he’s noticed any bleeding or change in stools that could indicate bleeding from the GI tract.

31. Answer: B. “What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?”This response encourages the client to get in touch with their feelings and utilize problem-solving steps to reduce guilt feelings.

32. Answer: C. Encourage her to talk about her view of herself.To an adolescent, body image is very important. The nurse must acknowledge this before assessment and teaching.

33. Answer: D. Discontinue a new food that was added to the infant’s diet just prior to the rash.The addition of new foods to the infant’s diet may be a cause of diaper dermatitis.

34. Answer: D. Feelings of alienation or isolation.The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self-imposed or can occur as a result of the inability to express feelings. At this stage of development, it is important to achieve a sense of identity and peer acceptance.

35. Answer: C. Independence. In Erikson’s theory of development, toddlers struggle to assert independence. They often use the word “no” even when they mean yes. This stage is called autonomy versus shame and doubt.

36. Answer: A. 60 microdrops/minute

2 gm=2000 mgm
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000
x= 2000/2000 = 1 cc of IV solution/minute
CC x 60 microdrops = 60 microdrops/minute

37. Answer: B. Oral contraceptives should not be used by smokers.The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.

38. Answer: C. Shallow respirations. A.L.S. is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.

39. Answer: A. “Nursing will help contract the uterus and reduce your risk of bleeding.” Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.

40. Answer: A. These side effects are common and should subside in a few days.Nausea, metallic taste, and fine hand tremors are common side effects that usually subside within days.

41. Answer: C. Encourage range of motion and ambulation.Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk.

42. Answer: A. Circumcision is delayed so the foreskin can be used for the surgical repair.Even if mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair, if needed.

43. Answer: A. Loss of consciousness.While parents should report any of the observations, they need to call the healthcare provider immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed or may be performed in stages.

44. Answer: A. Double the birth weight. Although growth rates vary, infants normally double their birth weight by 6 months.

45. Answer: C. Maintain in a flat position, logrolling as needed.The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while on bed rest.

46. Answer: A. “Focus on your son’s” needs during the first days at home.”In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.

47. Answer: A. A cerebral vascular accident.Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.

48. Answer: A. Oculogyric crisis.This refers to involuntary muscles spasm of the eye.

49. Answer: B. An occupational therapist from the community center.An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.

50. Answer: C. Provide interactions to help the client learn to trust staff.This establishes trust, facilitates a therapeutic alliance between staff and client.

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