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Atlas of Pediatric Physical Diagnosis
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Atlas of Pediatric Physical Diagnosis
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Test Bank For Basic Nursing: Thinking, Doing, and Caring withDavis Advantage and Davis Edge 2nd Edition By Leslie S Treas
9780803659421 Chapter 1-46 Complete Guide .
A nurse strokes along the lateral aspect of the bottom of the foot from the heel
toward the toes and then across the ball of the foot of a newborn. What reflex is the
nurse attempting to elicit?
1. Moro
2. Startle
3. Plantar
4. Rooting - ANSWER: plantar
Option 1:
The Moro and startle reflexes are one and the same. It occurs when the infant
responds to a loud noise with rapid abduction and extension of the arms, followed
by an embracing motion (adduction) of the arms.
Option 2:
The startle and Moro reflexes are one and the same. It occurs when the infant
responds to a loud noise with rapid abduction and extension of the arms, followed
by an embracing motion (adduction) of the arms.
Option 3:
This assesses the plantar reflex or Babinski's sign. With a positive response, the toes
will hyperextend and the big toe willdorsiflex. The presence of this sign is expected in
an infant younger than 6 months of age. If the Babinski's sign is absent, the infant
should be seen by a neurologist for a complete neurological examination.
Option 4:
The rooting reflex is elicited when the infant's cheek is stroked and the infant's
mouth turns toward the stimulus. By age 4 months, this reflex is gone when the
infant is awake, and gone at 7 months, when the infant is asleep.
A nurse is caring for a patient who is ordered out of bed in a chair for 1 hour twice a
day. The nurse is concerned about the complication of orthostatic hypotension.
What nursing action employed by the nurse will help to minimize the risk of
orthostatic hypotension?
1. Encourage the use of an incentive spirometer every 2 hours.
2. Massage the legs gently before moving to a sitting position.
,3. Teach ways to avoid the Valsalva maneuver when changing position.
4. Dangle the patient on the side of the bed for 1 minute before standing. - ANSWER:
4
Option 1:
An incentive spirometer helps minimize the risk of stasis of respiratory secretions,
not orthostatic hypotension.
Option 2:
The nurse should never massage a patient's legs because doing so could cause a
thrombus to become an embolus, which could cause a pulmonary embolus or other
life-threatening vascular occlusion.
Option 3:
Avoiding the Valsalva maneuver (exhalation pressed forcibly against a closed glottis)
causes a surge of blood to enter the heart, which can cause tachycardia and cardiac
arrest, not orthostatic hypotension.
Option 4:
When moving from a sitting and then to a standing position after being on bed rest,
venous blood pools in the lower extremities because of a decrease in the
vasopressor mechanism (muscle contraction that causes pressure on the veins,
promoting venous return). Having a patient sit for a minute after raising the head of
the bed and then having the patient sit on the side of the bed with the legs resting
on the floor (dangling) for a minute allows time for the blood pressure to equalize,
which minimizes the risk of orthostatic hypotension and a fall.
A nurse is changing the linens for a patient on bed rest. What should the nurse do to
prevent pressure (decubitus) ulcers when putting a bottom sheet on a bed?
1. Cover it with a draw sheet.
2. Make it with a toe pleat.
3. Change it every day.
4. Keep it wrinkle-free. - ANSWER: 4
Option 1:
A draw sheet is an additional sheet that can add to the number of wrinkles; the
purpose of a draw sheet is to keep the bottom sheet clean.
Option 2:
,A toe pleat should be placed in the top sheet and spread, not the bottom sheet. A
toe pleat prevents footdrop.
Option 3:
The bottom sheet does not have to be changed every day unless the sheet is wet or
soiled.
Option 4:
Wrinkles exert pressure and friction against the skin, promoting the formation of
pressure (decubitus) ulcers.
What is the priority when the nurse cares for an older adult in the community?
1. Maintaining quality of life
2. Supporting rehabilitation needs
3. Helping with bureaucratic paperwork
4. Encouraging interaction within the family - ANSWER: 1
Option 1:
This option is broad in scope and addresses improvement in all aspects of the life of
the older adult.
Option 2:
Supporting rehabilitation needs is only one part of caring for an older adult.
Option 3:
Helping with bureaucratic paperwork is only one part of caring for an older adult.
Option 4:
Encouraging interaction with the family is only one part of caring for an older adult.
Which nurse is demonstrating the planning phase of the nursing process?
1. A nurse who collaborates with a patient in designing a goal
2. A nurse who observes that a patient's urine is dark amber
3. A nurse who identifies a cluster of data as significant
4. A nurse who provides a backrub to induce sleep - ANSWER: 1
Option 1:
Identifying goals, outcomes, and planned interventions all are part of the planning
step of the nursing process.
Option 2:
, Identifying urine as dark amber is part of the assessment phase; in addition, it may
be part of the evaluation phase of the nursing process if the assessment is made
after providing care.
Option 3:
Determining the significance of data occurs during the analysis step of the nursing
process.
Option 4:
Providing nursing care occurs in the implementation phase of the nursing process.
Which manifestation should a nurse investigate first when assessing a client
admitted with severe pre-eclampsia that is being treated with a continuous infusion
of IV magnesium sulfate?
1. Oral temperature 100.6°F (38°C)
2. Pulse 110 bpm
3. Blood pressure 170/110 mm Hg
4. Respiratory rate 10 breaths per minute - ANSWER: 4
Option 1:
Although alterations in temperature are important to assess, respiratory alterations
should be the priority.
Option 2:
Although alterations in pulse rate are important to assess, respiratory alterations
should be the priority.
Option 3:
Although alterations in blood pressure are important to assess, respiratory
alterations should be the priority.
Option 4:
The nurse should first investigate the client's respiratory rate of 10 breaths per
minute because she may be experiencing profound respiratory depression related to
hypermagnesemia. Administration of IV magnesium sulfate places the client at
increased risk for hypermagnesemia and magnesium toxicity. A loss of patellar
reflexes, respiratory and neuromuscular depression, oliguria, and a decreased level
of consciousness are signs of magnesium toxicity.
A nurse is assisting a patient with range-of-motion exercises. What exercise is the
nurse performing when the palm of the patient's hand is turned up toward the
ceiling?
1. Eversion
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