NUR 146 MCN2 RLE P2 Exam

3/18/22, 7:19 AM NUR 146 (MCN2 RLE) P2 Exam
NUR 146 (MCN2 RLE) P2 Exam Total points 38/50
This is a multiple choice type of exam, you will answer this within 45 minutes. There will be
a deduction of 10 points for those who will submit beyond the time allotted. Please make
sure you have a stable internet connection. Full Name should be in CAPITAL letters.
The respondent's email (mica.delaserna.swu@phinmaed.com) was recorded on submission

of this form.
0 of 0 points
Family Name *
DELA SERNA
First Name *
MICAH MARIE
Section *
A4
Multiple Choice 38 of 50 points
Read each statement and select the best answer. Good luck!
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You are the nurse who is evaluating the care of a 9 year old child with 1/1
cerebral palsy. Which patient outcome should indicate the patient has
achieved a developmental milestone? *
A. The patient is able to feed themselves.
B. The patient's parents administer medications appropriately.
C. The patient has joined the Girl Scouts.
D. The patient returns for follow-up doctor's appointments as scheduled.
Jennifer is studying about abuse for the upcoming exam. For her to fully 0/1
instill the topic. she should know that the priority nursing intervention for
a child victim of abuse is: *
Assess the scope of the abuse problem.
Analyze family dynamics.
Implement measures to ensure the victim’s safety.
Teach appropriate coping skills.
The abnormal finding that a nurse would expect to observe during an 1/1
assessment of a 1 month old infant admitted to the hospital with
hydrocephalus would be that the: *
a. Infant’s anterior fontanel is tensed on palpation
b. Infant demonstrates poor eye or muscle coordination
c. Infant is unable to support the head and shoulders while prone
d. Infant’s head circumference is larger than the chest circumference
If a child is admitted with a possible neurologic condition, you would 1/1

expect the doctor to order measurement of what parameters? *
a. VS q 4 hours, head circumference OD
b. VS q 4 hours, head, chest and abdominal circumference OD
c. Head circumference OD, weigh OD
d. Head circumference q 4 hours, VS QID
A 2-year-old boy has shunt placement surgery done to relieve 0/1

hydrocephalus. He has postoperative nursing diagnosis of High Risk for
Injury: related to rapid reduction of intracranial pressure. Which of the
following would be an appropriate nursing intervention for Billy? *
a. Elevate the head of the bed 10 to 15 degrees
b. Place the child in low Trendelenburg position
c. Position the child flat on the shunt side
d. Position the child flat on the nonshunt side
A nurse has provided discharge instructions to the parents of an infant 1/1

who had a ventriculoperitoneal shunt procedure performed for the
treatment of hydrocephalus. Which statement if made by the parents
indicates an accurate understanding of the presence of a shunt
complication? *
a. “If my infant has a high-pitched cry, I should call the doctor.”
b. “I should position my infant on the side with the shunt when sleeping.”
c. “My infant will pass urine more often now that the shunt is in place.”
d. “I should call my doctor if my infant refuses baby food.”
A mother arrives at an emergency room with her 5-year-old child. The 1/1
mother states that the child fell off a bunk bed. A head injury is
suspected, and a nurse is assessing the child continuously for signs of
increased intracranial pressure (ICP). Which of the following would
indicate a late signs of increased ICP in this child? *
a. Nausea
b. Widened pulse pressure.
c. Dilated scalp veins
d. Bulging fontanel
A nurse hears that a new admission to the hospital was recently 1/1
diagnosed with acute lymphocytic leukemia. Which collaborative care
does the nurse prepare to provide to this patient? *
a. Antibiotic administration
b. Bone marrow transplant
c. Chemotherapy
d. Liver transplant
A parent brings a child to the clinic and reports that the child is reluctant 0/1
to walk and has a new limp. The parent also reports that the child seems
lethargic and tired all the time. The nurse notes that the child appears
pale. Which other finding would warrant immediate notification of the
health-care provider? *
a. Difficulty staying asleep at night
b. Left-sided abdominal enlargement
c. Polyphagia and polydipsia
d. Swelling of the legs and feet
A newly delivered mother with three young children at home comment 0/1
to the nursery nurse that she cannot hold the baby for feedings once she
gets home. She has just too much to do, and anyhow, it spoils the baby.
The best response for the nurse to make is: *
A. "You seem concerned about time. Let's talk about it."
B. "That's entirely up to you; you have to do what works for you."
C. "Holding the baby when feeding is important for development."
D. "It is very unsafe to prop a bottle. The baby could aspirate the fluid."
Option 5
A preschool-age child undergoing chemotherapy experiences nausea 1/1

and vomiting. Which of the following would be the best intervention to
include in the child's plan of care? *
a. Administer tube feedings.
b. Offer small, frequent meals.
c. Offer fluids only between meals.
d. Allow the child to choose what to eat for meals."
A 12 year old boy seen in the clinic, and a diagnosis of Hodgkin's disease 1/1
is suspected. Which diagnostic test results confirm the diagnosis of
Hodgkin's disease? *
a. Elevated vanillylmandelic acid urinary level.
b. The presence of blast cells in the bone marrow
c. The presence of Epsetin-Barr virus in the blood.
d. The presence of Reed-Sternberg cells in the lymph nodes
These are assessment findings for a child with ADHD, except: * 1/1
a. Fidgets with hands or feet and squirms in the seat
b. Easily distracted with external or internal stimuli
c. Careful with activities and considering possible consequences
d. Difficulty with following through on instructions
These are nursing interventions for a child with autism, except: * 1/1
a. Consistency is not necessary as much as possible
b. Determine the child’s routines, habits, and preferences
c. Determine the specific ways in which the child communicates
d. Use picture boards when communicating
The nurse is assessing a child diagnosed with posttraumatic stress 1/1

disorder (PTSD). Which finding should be the priority? *
a. History of suicide attempts
b. Changes in sleeping patterns
c. History of traumatic brain injury
d. Lack of social support
A macrosomic infant is born after a difficult forceps-assisted delivery. 1/1

After stabilization the infant is weighed, and the birth weight is 4550 g (9
pounds, 6 ounces). The nurse's most appropriate action is to: *
a. Leave the infant in the room with the mother.
b. Take the infant immediately to the nursery.
c. Perform a gestational age assessment to determine whether the infant is large for
gestational age.
d. Monitor blood glucose levels frequently and observe closely for signs of
hypoglycemia.
Infants of mothers with diabetes (IDMs) are at higher risk for developing: 0/1
*
a. Anemia.
b. Respiratory distress syndrome.
c. Hyponatremia.
d. Sepsis
On day 3 of life, a newborn continues to require 100% oxygen by nasal 1/1

cannula. The parents ask whether they can hold their infant during his
next gavage feeding. Given that this newborn is physiologically stable,
what response would the nurse give? *
a. "Parents are not allowed to hold infants who depend on oxygen."
b. "You may hold only your baby's hand during the feeding."
c. "Feedings cause more physiologic stress, so the baby must be closely monitored.
Therefore, I don't think you should hold the baby."
d. "You may hold your baby during the feeding."
A premature infant with respiratory distress syndrome receives artificial 1/1

surfactant. How would the nurse explain surfactant therapy to the
parents? *
a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and
carbon dioxide."
b. "The drug keeps your baby from requiring too much sedation."
c. "Surfactant is used to reduce episodes of periodic apnea."
d. "Your baby needs this medication to fight a possible respiratory tract infection."
When providing an infant with a gavage feeding, which of the following 1/1
should be documented each time? *
a. The infant's abdominal circumference after the feeding
b. The infant's heart rate and respirations
c. The infant's suck and swallow coordination
d. The infant's response to the feeding
Which is the ideal treatment for severe unmanageable hyperthyroidism 1/1

in a patient who is pregnant? *
a.Radioactive iodine
b. Subtotal thyroidectomy
c,Methimazole (Tapazole)
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The nurse should realize that the most common and potentially harmful 1/1
maternal complication of epidural anesthesia would be: *
A. Severe postpartum headache
B. Limited perception of bladder fullness
C. Increase in respiratory rate
D. Hypotension
Which of the following conditions would the nurse expect when 1/1
assessing a neonate for hydrocephalus? *
A. Bulging fontanel, low-pitched cry
B. Depressed fontanel, low-pitched cry
C. Bulging fontanel, eyes rotated downward
D. Depressed fontanel, eyes rotated downward
Dr. Jones prescribes corticosteroids for a child with nephritic syndrome. 0/1
What is the primary purpose of administering corticosteroids to this
child? *
A. To increase blood pressure
B. To reduce inflammation
C. To decrease proteinuria
D. To prevent infection
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Which factor is known to increase the risk of gestational diabetes 1/1

mellitus? *
a.Previous birth of large infant
b.Maternal age younger than 25
c.Underweight before pregnancy
d.Previous diagnosis of type 2 diabetes mellitus
A child with cancer has the following lab result: WBC 10,000, RBC 5, and 1/1
plts of 20,000. When planning this child's care, which risk should the
nurse consider most significant? *
A. Hemorrage
B. Anemia
C. Infection
D. Pain
Feedback
Correct answer: A Hemorrhage
The lab values presented all are normal except for the platelet count. Decreases in platelet
counts place the child at greatest risk for hemorrhage.
David, age 15 months, is recovering from surgery to remove Wilms' 1/1

tumor. Which findings best indicates that the child is free from pain? *
a. Decreased appetite
b. Increased heart rate
c. Decreased urine output
d. Increased interest in play
Feedback
Correct: D
Answer D. One of the most valuable clues to pain is a behavior change: A child who's pain-
free likes to play. A child in pain is less likely to consume food or fluids. An increased heart
rate may indicate increased pain; decreased urine output may signify dehydration.
When developing a teaching plan to prevent urinary tract infection, 1/1

which of the following should be included? (select all that apply) *
a) Wearing underwear made of synthetic materials such as nylon
b) Maintaining adequate fluid intake
c) Keeping urine alkaline by avoiding acidic beverages
d) Avoiding urination before and after intercourses
e) Avoiding bubble baths and tight clothing
f) Emptying bladder with each urination
Which of the following would the nurse expect when assessing a child 1/1
with cystitis? *
a) High fever
b) Flank pain
c) Costovertebral tenderness
d) Dysuria
Which of the following signs and symptoms are characteristic of 1/1

minimal-change nephrotic syndrome? *
a) Gross hematuria, proteinuria, fever
b) Hypertension, edema, hematuria
c) Poor appetite, proteinuria, edema
d) Hypertension, edema, proteinuria
The nurse is preparing Aurora for surgery to treat scoliosis. What would 0/1
the nurse include? *
A. Discomfort can be controlled with nonpharmacologic methods.
B. Ambulation will not be allowed for up to 3 months.
C. Surgery eliminates the need for casting and bracing.
D. Blood administration may be an option.
The pathological fractures of Alice revealed closed fractures in her left 0/1
femoral area. During physical examination, the following findings were
obtained: Swelling, redness, and tenderness of the affected site, PRS
8/10, HR 105 bpm, RR 24 bpm, BP 100/70 mmHg, and T 37.4 C. Which of
the following is the BEST nursing intervention for Alice? *
A. Further explore the patient’s pain
B. Encourage the patient to rest and elevate the affected area
C. Provide supplemental oxygenation
D. Encourage the patient to perform deep breathing exercises
This is a sexually transmitted infection that is caused by candida albicans. 1/1

*
A. Bacterial vaginosis
B. Gonorrhea
C. Vaginal candidiasis
D. Human papillomavirus
Nurse Loki created a nursing care plan tailored to the needs of the 1/1
patient with Anorexia Nervosa. His priority nursing diagnosis must
include which of the following? *
A. Decreased cardiac output
B. Body image disturbance
C. Risk for suicide
D. Risk for infection
Patients are prone to engage in dysfunctional behaviors if faced with 1/1

difficult situations. Alcoholism is considered what kind of abuse? *
A. Emotional Abuse
B. Substance Abuse
C. Verbal Abuse
D. Physical Abuse
Cinderella, 17 years old, is a victim of cyberbullying and already has three 0/1
(3) attempted suicides. At present, she is now experiencing suicidal
ideation. As a nurse, the BEST course of action is to: *
A. Notify the nurse’s station.
B. Never leave the patient’s side.
C. Prepare restraints.
D. Explore the patient’s feelings.
A patient was diagnosed with laryngotracheobronchitis. She presents 1/1

with increased temperature, irritability, restlessness, anorexia, and
hoarseness. Crackles and wheezes are only notable. Which of the
following findings is consistent with the case? *
A. ABG showing metabolic acidosis
B. ABG indicating respiratory acidosis
C. Throat swab with no growth
D. Throat swab with fungal growth
A patient was diagnosed with epiglottitis. The nurse is cognizant that this 1/1
can be an emergency. Which of the following is a classic sign of this
disorder? *
A. Increased temperature
B. Tripod positioning
C. Presences of rashes
D. Presence of cough
A patient was diagnosed with asthma. She presents with wheezing and 1/1
cyanosis. After three (3) doses of Salbutamol as inhalation, there is no
relief. Which of the following can possibly explain this? *
A. The patient is allergic to Salbutamol.
B. The patient is experiencing status asthmaticus.
C. The patient is experiencing cyanosis.
D. The patient is not in asthma.
A patient with pneumonia was prescribed with several medications. 1/1

Which of the following can reduce the bacterial load? *
A. Paracetamol
B. Salbutamol
C. Ceftriaxone
D. Albuterol
A woman in labor is at risk for abruptio placentae. Which of the following 1/1
assessments would most likely lead you to suspect that this has
happened? *
A) sharp fundal pain and discomfort between contractions
B) Painless vaginal bleeding and fall in blood pressure
C) pain in a lower quadrant and increased HR
D) an increased BP and oliguria
A nurse is monitoring a client with PROM who is in labor and observes 1/1
meconium in the amniotic fluid. What does the observation of meconium
indicate? *
A) cord compression
B) fetal distress related to hypoxia
C) infection
D) CNS involvement
A 32 year old gravida 3 para 2 at 36 weeks' gestation comes to the 1/1

obstetric department reporting abdominal pain. Her BP is 164/90, her HR
is 100 bpm, and her RR is 24 per minute. She is restless and slightly
diaphoretic with a small amount of dark red vaginal bleeding. What
assessment should the nurse make next? *
A) check DTRs
B) measure fundal height
C) palpate the fundus and check FHR
D) obtain a voided urine specimen, and determine blood type
A woman is in the 2nd trimester of pregnancy. Her blood pressure is 1/1

148/92, she has edema of the hands and feet, and her urine protein is 1+
dipstick. These data are indicative of: *
a) mild preeclampsia
b) severe preeclampsia
c) HELLP syndrome
d) eclampsia
A client with severe preeclampsia who has a BP of 170/110 mm Hg, a 1/1

pulse of 108 bpm, and respirations of 24 per minute is placed on IV
magnesium sulfate therapy. 8 hours later her BP is 150/110, the pulse is
98, and respirations are 10, and there is absence of knee-jerk reflex. The
nurse should:
A) wait 1 hour, monitor vitals and reflexes again, and then, if necessary discontinue
the infusion
B) stop the infusion of mag sulfate and notify the physician
C) administer calcium gluconate as antidote for magnesium sulfate
D) continue the mag sulfate infusion because the BP is still high
A client who is 24 hours postpartum has the following morning vital 0/1
signs: Temperature 99.8° F; BP 124/78; PR 58bpm; RR 16cpm. The nurse
should do which of the following? *
A. Recognize the client's vital signs are normal.
B. Assess the vital signs hourly instead of every 4 hours.
C. Retake the pulse rate after the client ambulates.
D. Report the changes in vital signs to the physician.
Which of the following behaviors would the nurse expect to observe in a 0/1
primipara client by the third postpartum day? *
A. Very talkative about the birth experience to friends
B. Greater interest in learning about infant care
C. Sleeping most of the time when the infant is not in the room
D. Requests for help with her activities of daily living
Based on the protocol of the Department of Health, after how many 0/1
weeks after delivery should a woman have her postpartal check-up? *
A. within a week
B. after 2 weeks
C. 4 weeks
D. 6 weeks
What is the nurse's best response for a client who asks, "How will sitting 1/1
in a sitz bath help me?" *
A. "It is the best way to prevent you from getting a uterine and episiotomy infection."
B. "It will increase your urinary bladder muscle tone and facilitate bladder emptying."
C. "The healing process is basically brought by the warm temperature of the
water."
D. "Sitting in the water promotes muscle contraction and prevents hemorrhaging."
The following are nursing interventions to relieve episiotomy wound pain 1/1
EXCEPT: *
A. Perineal heat
B. Perineal care
C. Giving analgesic as ordered
D. Sitz bath
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3/18/22, 7:19 AM NUR 146 (MCN2 RLE) P2 Exam

NUR 146 (MCN2 RLE) P2 Exam Total points 38/50

The respondent's email (mica.delaserna.swu@phinmaed.com) was recorded on submission

Multiple Choice 38 of 50 points

A. The patient is able to feed themselves.

B. The patient's parents administer medications appropriately.

C. The patient has joined the Girl Scouts.

D. The patient returns for follow-up doctor's appointments as scheduled.

Assess the scope of the abuse problem.

Analyze family dynamics.

Implement measures to ensure the victim’s safety.

Teach appropriate coping skills.

a. Infant’s anterior fontanel is tensed on palpation

b. Infant demonstrates poor eye or muscle coordination

c. Infant is unable to support the head and shoulders while prone

d. Infant’s head circumference is larger than the chest circumference

If a child is admitted with a possible neurologic condition, you would 1/1

a. VS q 4 hours, head circumference OD

b. VS q 4 hours, head, chest and abdominal circumference OD

c. Head circumference OD, weigh OD

d. Head circumference q 4 hours, VS QID

A 2-year-old boy has shunt placement surgery done to relieve 0/1

a. Elevate the head of the bed 10 to 15 degrees

b. Place the child in low Trendelenburg position

c. Position the child flat on the shunt side

d. Position the child flat on the nonshunt side

A nurse has provided discharge instructions to the parents of an infant 1/1

a. “If my infant has a high-pitched cry, I should call the doctor.”

d. “I should call my doctor if my infant refuses baby food.”

b. Widened pulse pressure.

c. Dilated scalp veins

b. Bone marrow transplant

a. Difficulty staying asleep at night

b. Left-sided abdominal enlargement

c. Polyphagia and polydipsia

d. Swelling of the legs and feet

A. "You seem concerned about time. Let's talk about it."

B. "That's entirely up to you; you have to do what works for you."

C. "Holding the baby when feeding is important for development."

A preschool-age child undergoing chemotherapy experiences nausea 1/1

a. Administer tube feedings.

b. Offer small, frequent meals.

c. Offer fluids only between meals.

d. Allow the child to choose what to eat for meals."

a. Elevated vanillylmandelic acid urinary level.

b. The presence of blast cells in the bone marrow

c. The presence of Epsetin-Barr virus in the blood.

d. The presence of Reed-Sternberg cells in the lymph nodes

a. Fidgets with hands or feet and squirms in the seat

b. Easily distracted with external or internal stimuli

c. Careful with activities and considering possible consequences

d. Difficulty with following through on instructions

a. Consistency is not necessary as much as possible

b. Determine the child’s routines, habits, and preferences

c. Determine the specific ways in which the child communicates

d. Use picture boards when communicating

The nurse is assessing a child diagnosed with posttraumatic stress 1/1