Health Promotion

The nurse assesses a 2-hour old newborn. The nurse notes the newborn's hands and feet are bluish in color. To which reason does the nurse attribute this finding? 1. A lack of adjustment to environmental temperature. 2. Poor perfusion of blood to the periphery of the body. 3. A lowered oxygen tension. 4. A low hemoglobin level.

1) Acrocyanosis is not related to the environmental temperature. 2) CORRECT - Acrocyanosis is a bluish color of hands and feet of the newborn. This is an expected finding and is caused by sluggish peripheral circulation. 3) Newborns have an elevated oxygen tension level. 4) Newborns have an elevated hemoglobin level level.

The nurse develops a teaching plan regarding nutrition for a pregnant client. Which information is appropriate for the nurse to include in the plan? 1. Protein requirements will triple during pregnancy. 2. Energy requirements will increase by 1200 calories/day. 3. Iron requirements will double during pregnancy. 4. Sodium should be restricted to 2 g/day.

1) Added protein is needed for metabolism and to support the growth and repair of maternal and fetal tissues. An intake of 60 g/day is recommended during pregnancy, which is not a triple increase. 2) A calorie increase of about 300 kcal/day is recommended to provide for the growth of the fetus, the placenta, amniotic fluid, and the maternal tissues. 3) CORRECT- The Dietary Reference Intakes (DRI) for iron is 15 mg/day for nonpregnant adult women and 30 mg/day for pregnant women. It is difficult to obtain this much iron from the diet alone, and most health care providers prescribe iron supplements of 30 mg/day beginning in the second trimester, after morning sickness decreases. 4) Sodium intake is essential for maintaining normal sodium levels in plasma, bone, brain, and muscle, because both tissue and fluid expand during the prenatal period. Sodium should not be restricted during pregnancy.

The nurse provides care for a client in the first trimester of pregnancy. The client experiences nausea. Which information does the nurse provide to the client? (Select all that apply.) 1. Nausea may be linked to the mother's acceptance of the pregnancy. 2. Nausea should diminish by the 14th week of pregnancy. 3. Eating a dry carbohydrate immediately upon arising is recommended. 4. Decreasing the intake of protein in the evening meal may help. 5. Avoid fried, spicy, and greasy foods.

1) CORRECT - Ambivalence about, or rejection of, the pregnant state may cause nausea. 2) CORRECT- Nausea begins about 4 weeks after the last menstrual period, and usually improves by the end of the 14th week of pregnancy. Nausea is associated with an increase of human chorionic gonadotropin (hCG) levels in early pregnancy. 3) CORRECT- Eating a dry carbohydrate upon waking up in the morning may help decrease nausea. 4) Eating more protein at night may help with nausea. 5) CORRECT - Avoiding fried, spicy, and greasy foods can help.

The nurse prepares to perform a breast examination on a 20-year-old female client. Which question is most important for the nurse to ask before beginning the examination? 1. "When was your last menstrual period?" 2. "Do you have a family history of breast cancer?" 3. "How much caffeine do you consume a day?" 4. "Have you ever had a mammography?"

1) CORRECT - Breast examination is ideally done about 1 week after the onset of menses, when hormonal influences on the breasts are at a low level. 2) INCORRECT - This does not need to be determined prior to the breast exam. 3) INCORRECT - This does not need to be determined prior to the breast exam. 4) INCORRECT - This does not need to be determined prior to the breast exam.

A nurse prepares to administer immunizations to a 4-year-old child. Which immunizations are appropriate for the nurse to administer? (Select all that apply.) 1. Inactivated poliovirus (IPV). 2. Pneumococcal conjugate (PCV13). 3. Haemophilus influenza type b (Hib). 4. Rotavirus (RV). 5. Measles, mumps, rubella (MMR).

1) CORRECT - The child should receive four doses of the IPV. The first dose at 2 months, a second dose at 4 months, the third dose between 6 and 18 months, and the fourth dose between 4 and 6 years of age. 2) The child should receive four doses of PVC13. The first dose at 2 months, a second dose at 4 months, the third dose at 6 months, and the fourth dose between 12 and 15 months. 3) The child should receive four doses of Hib. The first dose at 2 months, second dose at 4 months, the third dose at 6 months, and the fourth dose between 12 and 15 months. 4) If the child receives the 2-dose series, the first dose is given at 2 months and the second dose at 4 months. If the child receives the 3 dose series, the third dose is given at 6 months. 5) CORRECT - The child should receive two doses of MMR, the first dose at 12 to 15 months and the second dose between 4 and 6 years of age.

The nurse conducts a class for clients in their first trimester of pregnancy. Which information is appropriate for the nurse to include? (Select all that apply.) 1. Quickening should occur around 16 to 20 weeks' gestation. 2. The fundal height is the measurement from the top of the symphysis pubis to the top of the fundus. 3. Toddlers should be informed of the mother's pregnancy early on in the pregnancy. 4. Expected weight gain is 10 to 15 lb in the first trimester. 5. Nausea usually ends by 14 to 16 weeks.

1) CORRECT -Quickening should occur around 16 to 20 weeks' gestation. 2) CORRECT- The fundal height is measured from the top of the symphysis pubis, over the abdominal curve, to the top of the fundus. 3) Since toddlers have little perception of time, many parents delay telling them that a baby is expected until shortly before the birth. 4) Pregnant clients should not gain much weight in the first trimester. The majority of weight gain should occur in the second and third trimesters, at approximately 1 lb per week. For a client whose pre-pregnancy body mass index fell within normal limits, the total weight gain in pregnancy should only be 25 to 35 lb. 5) CORRECT - Nausea usually ends by 14 to 16 weeks' gestation.

The nurse receives several telephone messages when performing triage. Which client will the nurse direct to come to the health facility immediately? 1. Multipara client at four weeks' gestation reporting unilateral, dull abdominal pain. 2. Primigravida client at five weeks' gestation having vaginal spotting and some cramping. 3. Multigravida client at six weeks' gestation reporting frank, red vaginal bleeding with moderate cramps. 4. Primipara client at seven weeks' gestation reporting an increase in whitish vaginal secretions.

1) CORRECT -The client reporting unilateral dull abdominal pain needs to be evaluated immediately for an ectopic pregnancy. 2) INCORRECT - The client having vaginal spotting and cramping is describing symptoms of a threatened abortion and should be instructed to decrease activity. 3) INCORRECT - The client having frank red vaginal bleeding with moderate cramps is describing symptoms of a spontaneous abortion and should be instructed to save and count the pads. 4) INCORRECT - Whitish vaginal secretions is expected during the first trimester of pregnancy.

The nurse is teaching a class on contraception. Which client statement would require follow up teaching by the nurse? 1. "I should not use an oral contraceptive since I have a very heavy menstrual flow." 2. "I will need to quit smoking if I want to use birth control pills." 3. "I will need to use a contraceptive for several weeks after my spouse has a vasectomy." 4. "I know a condom needs to have a space left at the tip after it is put on an erect penis."

1) CORRECT- Oral contraceptives, including combination and progestin-only pills, reduce menstrual cramps and reduce menstrual flow. 2) INCORRECT- Smoking increases the risk of clot formation while taking oral contraceptives. Clients should stop smoking prior to taking oral contraceptives to reduce the risk of stroke, thromboembolic disease, or myocardial infarction. 3) INCORRECT- A vasectomy is not immediately effective. It may take up to 3 months post-vasectomy for seminal fluid to test negative for sperm. Other methods of contraception are required until a negative seminal fluid analysis is obtained. 4) INCORRECT- A client should allow for some space at the end of the condom by the head of the penis to collect semen in order to avoid breakage or spillage.

The nurse prepares to complete a health history with a client in a community clinic. Which action will the nurse take first? 1. Measure vital signs. 2. Determine major health problems. 3. Provide for physical and psychological comfort. 4. Develop the genogram.

1) INCORRECT - Vital signs can be measured after physical and psychological comfort are established. 2) INCORRECT - Major health problems can be assessed after physical and psychological comfort are established. 3) CORRECT - If the client is not physically and psychologically comfortable, the health assessment will not go as well as it could. This is the priority. 4) INCORRECT - A genogram can be developed after physical and psychological comfort are established.

The nurse provides care for a pregnant client. The client comes for a second prenatal visit at 15 weeks' gestation. The client's blood pressure is 120/72 mm Hg. The client's first blood pressure at 12 weeks' gestation was 124/80 mm Hg. Which action does the nurse take next? 1. Document the blood pressure. 2. Retake the blood pressure with the client in a side-lying position. 3. Review nutrition with the client to determine iron intake. 4. Notify the health care provider.

1) CORRECT- The client's systolic blood pressure usually remains the same as the pre-pregnancy level, but may decrease slightly as the pregnancy advances. Both of these values are within normal limits. Therefore, the nurse documents the blood pressure. 2) INCORRECT - The blood pressure should be taken with the arm in the horizontal position at heart level. This is not an appropriate action. 3) INCORRECT - There is no indication that the client is anemic or lacks iron. This is not an appropriate intervention. 4) INCORRECT - There is no need to notify the health care provider. Both blood pressures are within normal limits.

The nurse provides care for a client diagnosed with mild preeclampsia. Which assessment data, identified by the nurse, supports this diagnosis? (Select all that apply.) 1. Blood pressure of 150/96 mm Hg. 2. Urine output of 460 mL in a 24-hour period. 3. Platelet count of 110,000/mm3 (180 x 109/L). 4. 4+ proteinuria. 5. ALT level 30 U/L (0.50 µkat/L).

1) CORRECT—The criteria for mild preeclampsia include BP ≥ 140/90 mm Hg but ≤ 160/110 mm Hg. 2) An adequate urine output is seen with mild preeclampsia; oliguria (≤ 30mL/hr) is seen with severe preeclampsia. 3) A normal platelet count is seen with mild preeclampsia. Thrombocytopenia is seen with severe preeclampsia (HELLP syndrome); a normal platelet count is between 150,000 to 450,000/mm3 (150-450 x 109/L). 4) ≥ 1+ proteinuria is seen with mild preeclampsia; ≥ 3+ proteinuria is seen with severe preeclampsia. 5) CORRECT—Liver enzymes remain normal with mild preeclampsia. Elevated liver enzymes are seen with severe preeclampsia (HELLP syndrome); the normal ALT level is 10-40 U/L (0.17-0.67 µkat/L).

The nurse provides care for a 7-year-old client during a wellness examination. Which factor in the child's history alerts the nurse that hyperlipidemia screening is necessary? 1. Maternal history of obesity. 2. Paternal history of diabetes mellitus. 3. Sibling history of stroke. 4. Grandparent history of hypertension.

1) Hyperlipidemia screening is warranted in this age group if the child, not the mother, has a history of obesity. 2) Hyperlipidemia screening is recommended if the child in this age group has diabetes mellitus, not a parent. 3) CORRECT—If the child has a sibling with a history of stroke, screening for hyperlipidemia is recommended in children ages 2 to 8 years. 4) Hyperlipidemia screening is recommended for a child diagnosed with hypertension. It is not warranted if the child's grandparents have a history of hypertension.

The nurse prepares a client diagnosed with oral and esophageal candidiasis for discharge to home. Which statement from the client indicates to the nurse that teaching is successful? 1. "I will stop on the way home to get mouthwash at the store." 2. "I will swish the nystatin in my mouth before I spit it out." 3. "I think I will take it easy for a while by reading some books." 4. "I will cook with spices to cover the taste in my mouth."

1) INCORRECT - Commercial mouthwash should be avoided because of high alcohol content that irritates and dries out the oral mucosa, which is counterproductive to healing. Using warm saline, hydrogen peroxide, or biotene mouthwashes between nystatin doses is allowed. 2) INCORRECT - Nystatin is an antifungal agent in an oral suspension and should be swished around in the mouth and then swallowed to coat all affected surfaces. 3) CORRECT - Relaxation can help the immune system repair itself, and engaging in an enjoyable activity can be a distraction from the pain of the stomatitis and esophatitis. 4) INCORRECT - Soft, bland, non-acidic, and cool liquids and foods will help the eating process be more comfortable. Spicy foods, hot liquids, and citrus juices cause mucosal irritation. Even salty or peppered foods can increase irritation.

The nurse develops a teaching brochure about vision screening. Which statement is appropriate for the nurse to include in the brochure? 1. Children should have their eyes tested using the Snellen chart when they reach 2 years of age. 2. Adults age 65 and older should have the eyes examined every 5 years. 3. Adults between 40 and 60 years of age should have eyes tested for glaucoma every year. 4. Adults with type 1 diabetes mellitus should have a yearly eye exam, beginning at age 30.

1) INCORRECT - Tests are listed in decreasing order of cognitive difficulty. The highest test that the child is capable of performing should be used. In general, tumbling E or HOTV test should be used for children 3 to 5 years of age and Snellen letters or numbers for children 6 years and older. 2) INCORRECT - After the age of 65, people should have their eyes examined yearly. 3) INCORRECT - Adults between 40 and 60 years of age should have a glaucoma test every 2 years. 4) CORRECT - People with diabetes should have a dilated eye exam every year.

The home health nurse completes an assessment of a newborn. Which finding does the nurse expect during assessment? 1. "Machine-like" heart murmur. 2. Occipital frontal circumference 40 cm. 3. Bulging anterior fontanel at rest. 4. Extrusion reflex.

1) INCORRECT - This indicates patent ductus arteriosus, an acyanotic heart problem. 2) INCORRECT - The normal circumference for a newborn's head is 33-35 cm. An enlarged circumference would suggest hydrocephalus or increased intracranial pressure. 3) INCORRECT - The fontanels should not bulge at rest, although they may bulge when the infant is crying. 4) CORRECT— A normal neonate reflex that disappears between 3-4 months of age, the extrusion reflex is the tongue moving outward when the tongue is touched.

The parish nurse observes children at a church picnic. Which observation most concerns the nurse? 1. The spine of a 2-month-old is flexed forward and rounded when the child is held in a seated position. 2. The legs of an 18-month-old bend outward at the knees when the child stands and walks. 3. The legs of a 4-year-old touch at the knees when standing with the feet spread apart. 4. The arms of a 14-year-old appear different in length and there is a slight limp during ambulation.

1) INCORRECT - This is a normal finding. The spine is rounded or C-shaped in infants younger than 3 months of age due to the thoracic and pelvic curves. During the third and fourth months the cervical curve develops, and by 12 to 18 months the lumbar curve develops. 2) INCORRECT - This is a normal finding for a toddler. This is called genu varum and is referred to as bowleg. It is caused by lateral bowing of the tibia and lasts until all leg and lower back muscles are well developed, usually by 2 years of age. 3) INCORRECT - This is a normal variation for a child of 2-7 years of age. It is called genus valgum and referred to as knock-knee. 4) CORRECT — This indicates scoliosis, a spinal curvature deformity that is most noticeable during the growth spurt in preadolescence.

The nurse observes a 6-year-old client playing in the clinic playroom prior to the well-child checkup. Which activity demonstrates to the nurse that the client has musculoskeletal development that is age-appropriate, but not advanced? 1. The child runs after a rolling ball. 2. The child walks up and down the stairs. 3. The child hops and skips. 4. The child neatly ties the shoelaces.

1) INCORRECT — This is age-appropriate for child of 2 years of age. 2) INCORRECT — This is age-appropriate for a child of 2-4 years of age. 3) CORRECT — These are appropriate skills for a child of 4-6 years of age. 4) INCORRECT — This is an advanced motor skill that is accomplished after age 6.

The nurse teaches a group of teenage parents about infant nutrition and feeding. Which point does the nurse include in the teaching? 1. Sweeten foods with honey, not sugar. 2. Introduce fruit juice at age 4 months. 3. Avoid use of no-spill cups in infants 6 to 8 months of age. 4. Introduce strained, pureed, or mashed meats at 6 months of age.

1) INCORRECT— Honey should be avoided to prevent infantile botulism. 2) INCORRECT— Fruit juice offers no nutritional benefit in infants younger than 6 months of age. Infants younger than 6 months of age should only receive breastmilk or infant formula. 3) CORRECT— The use of no-spill cups is not recommended because they require sucking like using a bottle and do not encourage the infant to learn to drink from a cup. Additionally, they allow juice or milk to be in constant contact with the teeth, increasing the risk for dental caries. 4) INCORRECT— Strained, pureed, or mashed meats can be introduced at 10 to 12 months of age.

A nurse in the pediatric clinic discusses the potential of lead exposure with the parents of preschoolers. It is most important for the nurse to follow up on which statement made by a parent? 1. "I use water from the cold water tap for cooking." 2. "My child likes to finger paint." 3. "My spouse renovates old houses." 4. "My child is very good about eating regular meals."

1) INCORRECT— Hot water dissolves lead in pipes more quickly and contains higher levels of lead than cold water. The parent should use cold water for drinking and cooking. 2) INCORRECT— Artists' paints may contain lead, but lead is not found in finger paints. 3) CORRECT— Construction and lead abatement workers may bring home lead dust that children can inhale. Homes built prior to 1950 contain lead-based paints. Homes built between 1950 and 1978 may contain lead on exterior surfaces. The parent should shower and put on clean clothing prior to coming home. 4) INCORRECT— This is an appropriate action. More lead is absorbed on an empty stomach.

The nurse teaches the client about preventing recurrent urinary tract infections. Which statement by the client indicates to the nurse that teaching is effective? (Select all that apply.) 1. "I should bathe in the tub rather than shower." 2. "Coffee and alcohol are good for my bladder." 3. "Vitamin C will help by acidifying my urine." 4. "I should void every couple of hours during the day." 5. "I should wipe back to front after urinating."

1) INCORRECT— The client should shower rather than bathe in a tub because bacteria in bathwater may enter the urethra. 2) INCORRECT— The client should avoid coffee and alcohol as they are known urinary tract irritants. 3) CORRECT— Vitamin C (ascorbic acid) 1000 mg daily, or cranberry juice, may help prevent recurrent urinary tract infections by acidifying the urine. 4) CORRECT— Voiding frequently prevents over distention of the bladder and compromised blood supply to the bladder wall. 5) INCORRECT— The client should clean the urethral meatus and perineum front to back after a bowel movement or after urination to avoid transmitting fecal bacteria to the urethra.

The nurse provides care for a young adult female client diagnosed with type 1 diabetes mellitus (DM). When teaching the client about measures to prevent long-term complications, which instruction does the nurse include? 1. "Use a vaginal douche after each menstrual period." 2. "Wear cotton undergarments." 3. "Limit your fluid intake to 2 liters per day." 4. "Empty your bladder every 6 hours."

1) INCORRECT— Using a vaginal douche increases the risk of vaginal infections, especially yeast infections. Female clients with diabetes are at higher risk for vaginal infections due to the altered glucose metabolism. The nurse will instruct the client to avoid the use of vaginal douches. 2) CORRECT — The nurse will encourage the client to wear undergarments made of natural fibers, such as cotton, which are more breathable than synthetic fibers. Cotton undergarments tend to absorb moisture more effectively than other materials and allow air to circulate better, decreasing the risk of vaginal infection. 3) INCORRECT— The female client with diabetes should be encouraged to drink plenty of fluids. Staying hydrated will flush the urinary tract on a regular basis and decrease the risk of urinary tract infection. The client with diabetes is at higher risk for urinary tract infection and should take measures to reduce that risk, including adequate fluid intake. 4) INCORRECT— The client with DM is at higher risk for urinary tract infection. Delayed emptying of the bladder results in urine stasis and increased risk of infection. The nurse will instruct the client to frequently empty the bladder to reduce the risk of infection.

The nurse is teaching a group of clients who are all over the age of 50 years about the screening tests for colorectal cancer. Which screening recommendation does the nurse include in the teaching? 1. Annual prostate-specific antigen. 2. Fecal occult blood every 3 years. 3. Colonoscopy every 10 years. 4. Barium enema every year.

1) Prostate-specific antigen is a test which may be used to help screen for prostate cancer. 2) If fecal occult blood testing is selected as a screening for colorectal cancer, it should be done every year. 3) CORRECT - Clients who are 50 years of age or older should have a colonoscopy every 10 years. 4) If a barium enema is selected as a screening for colorectal cancer, it should be done every 5 years.

The nurse is assessing a client who is at 10 weeks' gestation. Which assessment finding does the nurse expect to see? 1. Striae and linea nigra on the abdomen. 2. Chloasma over the facial cheeks. 3. The client reports leg cramping at night. 4. Enlargement of the client's breasts.

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