- (Topic 4)
A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the client that to regulate the bowel, colostomy irrigation should be performed at the same time each day. The best time is:

1. A. After meals
2. B. Before meals
3. C. Every 2 hours
4. D. At bedtime

Correct Answer: A
(A) Bowel movements should be regulated at a specific time each day to prevent ??accidents.?? Irrigating after meals takes advantage of the gastrocolic reflex and time of increased peristalsis, so better results may be produced. After meals is the normal time that peristalsis begins in most persons and evacuation of feces occurs. (B) Irrigating before meals may cause poor results because of decreased gastrocolic reflex and decreased peristalsis. (C) Irrigating a colostomy every 2 hours may produce hyperactivity of the bowel, leading to irritation and diarrhea. This would not aid in regulation of the bowel. (D) If irrigation of a colostomy were done at bedtime, there is greater chance of having an ??accident?? during sleep. This would not be an advantageous practice of bowel regulation.

- (Topic 1)
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:

1. A. Sustained temperature elevation over 103F is generally related to febrile seizures
2. B. Febrile seizures do not usually recur
3. C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
4. D. Febrile seizures are associated with diseases of the central nervous system

Correct Answer: C
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.

- (Topic 4)
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

1. A. Hyperextension of the neck with evidence of pain on flexion
2. B. Holding the head to one side and pointing the chin toward the other side
3. C. Holding the head erect and in the midline when in a vertical position
4. D. Significant head lag when raised to a sitting position

Correct Answer: D
(A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.

- (Topic 4)
The nurse documents a client??s surgical incision as having red granulated tissue. This indicates that the wound is:

1. A. Infected
2. B. Not healing
3. C. Necrotic
4. D. Healing

Correct Answer: D
(A) The wound is not infected. An infected wound would contain pus, debris, and exudate.
(B) The wound is healing properly. (C) A necrotic wound would appear black or brown. (D) The wound is healing properly and is filled with red granulated tissue and fragile capillaries.

- (Topic 7)
The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:

1. A. Alopecia is an unavoidable side effect.
2. B. There are several wig makers for children.
3. C. Most children select a favorite hat to protect their heads.
4. D. His hair will grow back in a few months.

Correct Answer: D
(A) Alopecia has occurred, and knowing it is a side effect does not address their concern.
(B) Although true, it does not give them hope for the future. (C) Although true, it does not provide them with information of the temporary nature of the situation. (D) Knowing the hair will grow back provides comfort that the alopecia is temporary.