health promotion and maintenance

The nurse is assessing a 19-year-old male client at a well visit. Which of the following statements by the client indicates an expected body image change in this age group? "I wish I wasn't so tall and lanky." "I am ready to settle down and start a family." "I like to work out and build muscle." "I am tired of having acne and this patchy beard."

"I like to work out and build muscle." Rationale: In the late adolescent period into early adulthood, clients often build muscle more efficiently, and the statement that the client enjoys this physical change is an expected finding. While acne and inconsistent facial hair may still exist at 19 years of age, the client's statement indicates a negative outlook on these changes. Starting a family does not affect body image.

The nurse is informed by a client that her home pregnancy test was positive. The client asks what the pregnancy test is looking for. Which response by the nurse is appropriate? "The home pregnancy test is looking for the body's release of estrogen." "The pregnancy test is looking for the human chorionic gonadotropin hormone." "The test is looking for the presence of alpha-fetoprotein." "The pregnancy test is looking for an absence of progesterone."

"The pregnancy test is looking for the human chorionic gonadotropin hormone." Rationale: Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy. Progesterone is the hormone that maintains pregnancy, and when its levels drop, the woman will go into labor. Estrogen is at its highest level during pregnancy, however, it is not tested on a pregnancy test. Alpha-fetoprotein is part of a screening for birth defects.

The nurse is speaking with the parents of a 5-year-old boy who is diagnosed with hemophilia A. The parents recently underwent genetic counseling that showed that the mother is a carrier and the father is unaffected. The parents are asking the nurse what the chances are of having another child with this genetic disorder. How should the nurse respond? "There is a 50% probability that another male child would have this disease." "All daughters will be carriers of this disease." "There is a 25% probability that daughters will be a carrier of this disease." "All of your male children will have this disease."

"There is a 25% probability that daughters will be a carrier of this disease." Rationale: Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. When the carrier mother and the unaffected father are pregnant, there are four possible outcomes: a 25% (one in four) chance of having a son without hemophilia a 25% (one in four) chance of having a son with hemophilia a 25% (one in four) chance of having a daughter who is a carrier a 25% (one in four) chance of having a daughter who is not a carrier

The nurse is planning to give a 3-year-old child oral digoxin. Which action is the best approach by the nurse? "You will feel better if you take your medicine." "Do you want to take this pretty red medicine?" "Would you like to take your medicine from a spoon or a cup?" "This is your medicine, and you must take it all right now."

"Would you like to take your medicine from a spoon or a cup?" Rationale: At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine allows the child to express an opinion and have some control.

The nurse is educating adolescent clients about safe sex practices. Which of the following statements should be included in the teaching? "You should wear a condom every time you have sexual intercourse." "Abstinence is the only way to reduce your risk of pregnancy." "Oral contraceptives are the most effective way to prevent sexually transmitted infections (STIs)." "You can tell if someone has an STI because they will have genital lesions."

"You should wear a condom every time you have sexual intercourse." Rationale: A barrier method of contraception (such as a condom) is the only way to reduce the risk of STI transmission; therefore, education about the importance of condom use is important to include in the education. Abstinence is the only way to completely prevent pregnancy, but there are other forms of contraception that reduce the risk of pregnancy. Oral contraceptives do not reduce the risk of STIs, and there are many STIs that do not have visual clinical manifestations.

The nurse is preparing to discharge a postpartum client who has a history of postpartum depression after the birth of the first child. Which follow-up care should the nurse include in the plan for this client? An appointment with a mental health counselor, scheduled prior to discharge An appointment with the obstetrician in 6 weeks, scheduled prior to discharge One visit from a homecare nurse to take place in 2 days, scheduled prior to discharge Two visits from a lactation consultant over the next month

An appointment with a mental health counselor, scheduled prior to discharge Rationale: Postpartum depression (PPD) is a form of clinical depression that can affect women after childbirth. Unlike the postpartum blues, women with postpartum depression feel worse over time, and changes in mood and behavior do not go away on their own. Different from baby blues, the symptoms of PPD last longer, are more severe, and require treatment. Based on the woman's history of prior depression, prophylactic antidepressant therapy may be needed during the third trimester or immediately after giving birth. Management mirrors that of any major depression: a combination of antidepressant medication, antianxiety medication, adequate sleep and rest, and psychotherapy in an outpatient or inpatient setting.

The nurse is caring for a pediatric client who states, "My parents got divorced. I live with my mom sometimes, and I live with my dad other times." How should the nurse document this family structure in the medical record? Nuclear family Binuclear family Cohabitating family Dyadic family

Binuclear family Rationale: Separated parents who assume joint custody of children are considered binuclear families. Nuclear families are structures in which the parents and children live together. Cohabitating families live in one home but are not married or legally bound together. Dyadic families have no children.

A hospitalized, school-age child with a spica cast says to the nurse "I am bored." Which type of activity would be most appropriate for the nurse to implement for this child? Unlimited television time Push-pull toys Jump rope Board games

Board games Rationale: School-age children enjoy activities which promote physical growth, intellectual ability and fantasy. With the spica cast, vigorous physical activity will be limited. Quiet activities include reading, arts and games. The nurse should discourage unlimited television or electronic screen time. Push-pull toys would be more appropriate for younger children, such as toddlers.

The nurse is caring for a client who is requesting a prescription for oral contraceptives. Which of the following conditions is considered a contraindication for this contraceptive method? Irregular menstruation Allergy to penicillin History of asthma Diabetic neuropathy

Diabetic neuropathy Rationale: Hormonal contraceptives are contraindicated for clients who have diabetic neuropathy, diabetic retinopathy, diabetes for more than 20 years, vascular disease, history of stroke, VTE, liver tumors, heart disease, and other conditions. Asthma, penicillin allergy, and irregular menstrual cycles are not contraindications.

The nurse is teaching a 10-year-old child prior to heart surgery. Which form of explanation is best for this client? Provide the child with a booklet to read about the surgery Provide a verbal explanation just prior to the surgery Explain the surgery using a model of the heart Introduce the child to another child who had heart surgery three days ago

Explain the surgery using a model of the heart Rationale: According to Piaget, the school-age child is in the concrete operations stage of cognitive development. The use of something concrete, such as a model, will help the child understand the explanation of the heart surgery. The other options are not appropriate for the developmental age, or they are not therapeutic methods of teaching children.

The nurse is observing a 6-year-old client at a well visit. Which of the following findings indicate that the client is experiencing developmental delays? Writing words with spelling errors Expressing interest in reading Asking the provider for more toys Fixating on a brightly colored object

Fixating on a brightly colored object Rationale: A 6-year-old client should demonstrate the ability to write words but may reverse letters or misspell words. They also find enjoyment in reading quietly. Toys are still an important part of play at 6-years-old and often hold more importance than imaginative play. Brightly colored objects are attractive to children but a fixation on objects is a concern. Fixation on bright objects or lights is normal for infants and toddlers, but this behavior typically disappears in the school-aged child.

During an assessment of a postpartum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. The nurse identifies which condition as the most likely cause of these findings? Retained placenta Genital lacerations Uterine atony Clotting disorder

Genital lacerations Rationale: Continuous trickling of blood in the absence of a boggy fundus indicates undetected genital tract lacerations. The nurse should notify the health care provider, as the client may need surgical intervention to stop the bleeding. The nurse should begin to weigh peripads to document blood loss. All other options would present with a boggy fundus due to impeding contractions of the uterus or it filling with blood.

A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about the client's obstetric history which includes 3-year-old twins and a miscarriage 10 years ago. How should the nurse accurately document this information? Gravida 3 para 1 Gravida 3 para 2 Gravida 4 para 2 Gravida 2 para 1

Gravida 3 para 1 Rationale: Para is the number of deliveries (of an infant more than 20 weeks gestation). Regardless of how many babies are delivered at one time (twins, triplets, etc.), the delivery is still counted as 1. Gravida is the number of pregnancies. This woman had a miscarriage (at 12 weeks), so that would be gravida 1, para 0. With the twins, the count would be gravida 2, para 1. With the current pregnancy, she is gravida 3, para 1 - 3rd pregnancy to date, but only one previous delivery (of the twins).

A newborn baby that was delivered at home without a birth attendant is admitted to the hospital for observation. The baby's initial temperature is 95° F (35° C). The nurse should recognize that the newborn is at risk for which complication? Lowered basal metabolic rate Hypoxemia Hyperglycemia Metabolic alkalosis

Hypoxemia Rationale: This newborn has hypothermia and it at risk for cold stress. This can cause a variety of physiologic stresses including increased oxygen consumption and reduced partial pressure of oxygen in arterial blood or PaO2, i.e., hypoxemia. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97°F (36°C). Normal core body temperature for newborns is 97.7° F-99.3° F (36.5° C-37.3° C)

A nurse is providing contraceptive education to a 21-year-old woman. When discussing hormonal birth control, what additional benefits would the nurse most likely include? Reduced risk for migraine headaches Decreased risk of depression Protection against blood clots Improvement in acne symptoms

Improvement in acne symptoms Rationale: Oral contraceptives (OC) can make menstruation regular, lighter, and less painful, reduce the risk of ovarian, uterine, and colon cancer, reduce symptoms of premenstrual syndrome, reduce acne, protect against pelvic inflammatory disease, and reduce the risk of fibroids, ovarian cysts, and non-cancerous breast disease. OCs increase the risk of blood clots and myocardial infarction and can slightly increase the risk of breast cancer.

A breastfeeding client would like to increase her milk production. What should the nurse recommend? Increase the frequency of feedings or breast pump uses Add foods high in unsaturated fats Reduce the frequency of feedings or breast pump uses Use supplemental formula feedings

Increase the frequency of feedings or breast pump uses Rationale: Milk production is driven by supply and demand. The more milk that is expressed from the breast, the more milk is produced. Reducing the number of feedings or supplementing with formula will reduce the production of milk. Increasing dietary fat will have no effect on milk production.

A client comes to the prenatal clinic for her first visit. After identifying that September 7th was the first day of the client's last menstrual period, the nurse informs the client that the estimated date of delivery is which of the following? June 14th June 7th July 7th July 1st

June 14th Rationale: Nagele's Rule for calculating due date: Subtract three months from the first day of the last period and add seven days. Alternatively, count 40 weeks, or 280 days, from the first day of the last menstrual period (LMP). This is an estimate, based on the assumption that ovulation occurred on day 14 of the menstrual cycle.

The home health nurse is educating a client who was discharged 2 days ago about the symptoms of postpartum metritis. Which finding should the nurse include in the teaching? Lower abdominal tenderness Urinary frequency Mild reddish lochia Perineal soreness and edema

Lower abdominal tenderness Rationale: Metritis is an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus. It occurs within the first two days postpartum or as late as two to six weeks postpartum. Symptoms of metritis are lower abdominal pain and uterine tenderness, followed by fever, most commonly within the first 24 to 72 hours postpartum. Chills, headaches, malaise, and anorexia are common. Sometimes the only symptom is a low-grade fever.

A 9-year-old child is taken to the emergency department with right lower quadrant pain and vomiting. During preparation for an emergency appendectomy, what should the nurse expect to be the child's greatest fear? Perceived loss of control An unfamiliar environment Change in body image Guilt over being hospitalized

Perceived loss of control Rationale: According to Erikson's stage of development, this child is in the industry versus inferiority developmental stage. The age range for this stage is 5 to 13 years. Within this stage, children learn new skills and are influenced by their peers. They may feel competent or feel inferior and doubt themselves. Possible problems or concerns could include isolation from peers, inability to cope causing anger and shame, self-doubt, and perceived loss of control.

When teaching new parents prevention of sudden infant death syndrome (SIDS) what is the most important practice a nurse should instruct them to do? Do not allow anyone to smoke in the home Place the infant in a supine position for sleep Follow recommended immunization schedule Obtain a home monitor system to hear the sounds from the infant

Place the infant in a supine position for sleep Rationale: Research suggests that the cases of SIDS is reduced when newborns sleep on their back. The theory behind SIDS is that the infant becomes hypoxic when they sleep due to positional narrowing of the airway plus respiratory inflammation. Exposure to second-hand smoke is a cause of SIDS and it is important that no one smokes in the home--the evidence shows that the "back to sleep" campaign has drastically reduced the incidence of SIDS. There is no association between immunizations and SIDS.

The nurse is assigned to work on an adolescent medical-surgical unit. Which of these client needs would the nurse expect to observe? Privacy, autonomy, peer interactions Independence, confidence, narcissism School performance, reading, journal writing Interest in sports, competition, being right

Privacy, autonomy, peer interactions Rationale: Adolescents display the need for privacy, autonomy and peer interaction concurrent with an evolving sense of identity.

The nurse is evaluating a client's ability to care for a newborn. Which action by the client indicates the need for education? Changing the baby's diaper on the bed Holding the baby with one hand while feeding Giving the baby a pacifier while swaddled Putting the baby to sleep in the prone position

Putting the baby to sleep in the prone position Rationale: A baby should be placed to sleep alone on their back in a crib or bassinet. The client placing the baby in the prone position indicates the need for education. All other responses do not warrant nursing action.

The nurse is monitoring oxygen saturation levels of preterm infants in the neonatal intensive care unit (NICU). Which of the following complications of oxygen therapy in preterm infants is the most common? Necrotizing enterocolitis Retinopathy of prematurity (ROP) Bronchopulmonary dysplasia (BPD) Hyperbilirubinemia

Retinopathy of prematurity (ROP) Rationale: In addition to birth weight and how early the infant is born, many factors contribute to the risk of ROP. But prolonged exposure to high concentrations of oxygen will cause irreversible damage to the eyes of preterm infants. Severe ROP is significantly reduced by keeping SpO2 levels stable and within narrow target ranges. BPD develops as a result of an infant's lungs becoming irritated or inflamed by mechanical ventilation, high levels of oxygen, infections, as well as heredity. Necrotizing enterocolitis and hyperbilirubinemia are problems associated with prematurity, but not oxygen therapy.

The nurse is planning care for a 2-year-old hospitalized child. Which issue will produce the most stress at this age? Separation anxiety Loss of control Bodily injury Fear of pain

Separation anxiety Rationale: Toddlers experience separation from their parents as a major stressor. Separation anxiety peaks in the toddler years and will produce the most stress at this age.

The nurse is performing a home safety assessment for an older adult client with limited mobility. Which of the following findings should the nurse identify as a safety risk? A night light plug-in located in each room Several rugs present throughout the home Grab bars located next to the toilet Multiple locks on the exterior doors

Several rugs present throughout the home Rationale: Older adults are at a higher risk of falling and identification of items that increase the risk of falls is important. Items that increase the risk of falls include uneven floor surfaces (rugs, steps, etc.), poor lighting, or cluttered walkways. Having a nightlight in each room helps to increase visibility and therefore reduces the risk of falls. Grab bars in the shower or next to the toilet reduce the risk of falling in the bathroom, and the number of locks on the exterior doors do not pose a safety risk for the client.

The nurse is caring for a client who states, "My partner got remarried, and now I have to take care of the kids without any help." What kind of family structure should the nurse record in the client's chart? Single-parent family Nuclear family Blended family Contemporary family

Single-parent family Rationale: A single-parent family is a home in which one member of the family is responsible for 100% of the adult responsibilities within that family unit. Nuclear families are structures in which the parents and children live together. Contemporary families/contemporary nuclear families may include same-sex marriage. Blended families are those who have children from previous relationships within the same family unit.

The nurse is screening clients at a community center for risk factors of hypertension. Which reported activity places the client at a higher risk for developing hypertension? Drinking 1-2 glasses of wine per week Traveling out of state 1 time per month Exercising 2-3 days per week Smoking 1 pack of cigarettes per day

Smoking 1 pack of cigarettes per day Rationale: Lifestyle choices that are risk factors for the development of hypertension include drinking more than one glass/day of alcohol for females and two glasses/day of alcohol for males, tobacco use, a sedentary lifestyle, and excessive dietary sodium intake often found in fast-food restaurants meals. Frequent travel has not been identified as a risk factor for the development of hypertension.

A nurse is teaching a group of adults about modifiable risk factors for cardiovascular disease. Which risk factor is most important to include? Physical exercise Weight reduction Smoking cessation Stress management

Smoking cessation Rationale: Smoking cessation is a priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time, but the priority modifiable cardiac risk factor is smoking.

The nurse is providing anticipatory guidance to the parents of a 6-month-old infant. Which intervention should the nurse recommend to support the development of trust? Provide warm blankets to facilitate sleep Offer feedings on a strict, set schedule Do not allow the child to be held for too long Tend to the child quickly when it begins to cry

Tend to the child quickly when it begins to cry Rationale: Social and emotional development is based on trust, love, and security. The best way to develop trust is to consistently and promptly meet the infant's needs. When an infant cries, it is a way for the infant to communicate a need such as being hungry, wet, in pain, or scared. By attending to a crying infant quickly, it will help to establish trust. The other interventions will not help to promote the development of trust in the child.

The community health nurse is planning a teaching session for a family with children about safety and risk-reduction in their home. What information is most important to obtain prior to the session to ensure the teaching is effective? The ages of the children in the home. The ages and occupations of the parents. The physical layout of the home. The number of children in the home.

The ages of the children in the home. Rationale: Although all of the information is important for the nurse to consider, the ages and developmental levels of the children are the most important considerations for anticipatory guidance associated with safety, and should be given priority when developing a teaching plan. With this information, the nurse can individualize the teaching session to meet the specific needs and risks of the children in the home.

The nurse is assessing a 5-day-old infant brought to the pediatrician's office by the infant's parents. During the assessment, the nurse identifies clear breath sounds with equal chest expansion, a respiratory rate of 38 to 42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings? The infant should be seen immediately by the pediatrician The infant will require emergency lifesaving services The infant's breathing pattern is normal The infant will need a referral to a respiratory specialist

The infant's breathing pattern is normal Rationale: Respiratory rates in newborns (first four weeks of life) are 30 to 60 breaths per minute. Newborn infants breathe faster than children and adults. Periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the infant's parents that this is an expected finding and is known as "periodic breathing" and occurs as the newborn's lungs and brains become more coordinated. Although the pediatrician should examine the infant, it is not imperative that the infant be seen immediately. The infant is not in any respiratory distress. The nurse's assessment findings for the infant are normal. At this point, there is nothing in the nurse's assessment that would indicate that the infant will need a referral to a respiratory specialist or require emergency lifesaving intervention.

The nurse is assessing a client who has aortic stenosis. Where should the nurse place the stethoscope to auscultate for this abnormal heart sound? The third intercostal space at the mid-axillary line The fourth intercostal space at the mid-clavicular line The sixth intercostal space at the left sternal border The second intercostal space at the right sternal border

The second intercostal space at the right sternal border Rationale: The aortic valve is best auscultated at the second intercostal space at the right sternal border.

During the two-month well-baby visit, the mother explains that formula seems to stick to her baby's mouth and tongue. Which assessment would provide the most valuable data for a nurse? Inspect the baby's mouth and throat Flush both sides of the mouth with normal saline Obtain cultures of the mucous membranes Use a soft cloth to attempt to remove the patches

Use a soft cloth to attempt to remove the patches Rationale: Candidiasis can be distinguished from coagulated milk when attempts to remove the patches with a soft cloth are unsuccessful or trigger bleeding of the tongue under the white substance.

The nurse is performing a physical assessment on a toddler. Which approach should the nurse initially take when assessing toddlers? Perform traumatic procedures first Use minimal physical contact initially in the exam Explain the exam in detail as areas are examined Proceed from head to toe in a sequential manner

Use minimal physical contact initially in the exam Rationale: The nurse should approach a toddler slowly and use minimal physical contact initially so as to gain the toddler's cooperation. Other approaches with this age group are to be flexible in the sequence of the exam and give only brief simple explanations just prior to any action.

A nurse is caring for a 48-year-old client who is experiencing irregular menstrual periods and has started having hot flashes. The nurse should expect the client to report which finding associated with perimenopause? Weight loss Sleeping for prolonged periods without dreaming Chills at night Vaginal dryness during sexual intercourse

Vaginal dryness during sexual intercourse Rationale: During the perimenopausal years (2 to 8 years prior to menopause), women may experience physical changes associated with decreasing estrogen levels, which may include vasomotor symptoms of hot flashes, irregular menstrual cycles, sleep disruptions, forgetfulness, irritability, mood disturbances, weight gain and bloating, irregular menses, headaches, decreased vaginal lubrication, night sweats, fatigue, vaginal atrophy, and depression.

The nurse is caring for an adult client admitted to the hospital for hyperosmolar hyperglycemia who will now be using insulin at home. In addition to answering all the client's questions, which of the following interventions will be most effective in maximizing the client's self-care abilities? Verbalize step-by-step directions while drawing up the medication and administering the injection to the client Demonstrate to the spouse how to draw up and administer the injection and ask if they have any additional questions Provide the client with an instructional video and then watch them perform a return demonstration Schedule a homecare visit for diabetic teaching and provide the client with verbal and written instructions on insulin administration

Verbalize step-by-step directions while drawing up the medication and administering the injection to the client Rationale: The plan of nursing care should include specific education to promote self-care and independence. Psychomotor skills teaching should include a demonstration by the nurse and then a return demonstration by the client. Teaching the caregiver does not promote self-care. The nurse should be an active participant in client education using videos as a resource and not the primary source of education. Teaching should begin during admission and be reinforced by outside services.

The nurse is caring for a client during a routine prenatal visit. Which action by the client indicates that the client is not coping with the physical changes of pregnancy? "My breasts have grown so much that I need new bras." "I don't feel like getting on the scale today." "My belly is so big that I can't see my toes anymore." "I exercise twice a week so that I don't gain too much weight."

"I don't feel like getting on the scale today." Rationale: In pregnancy, women gain a significant amount of weight. Statements such as "I don't feel like getting on the scale" or "I don't want to look at myself" may indicate that the client is not accepting the expected body changes of pregnancy. The other statements do discuss weight gain but do not indicate that the client's body image has been negatively impacted.

The nurse is teaching child preparation classes to a group of parents. One couple asks about their rights to develop a birth plan. Which response by the nurse would be most appropriate? "Have you talked with your health care provider about this?" "What is your reason for wanting such a plan?" "Let us discuss your rights as a couple." "Write your ideal plan for the next class."

"Let us discuss your rights as a couple." Rationale: The most appropriate response from the nurse would be to discuss their rights as a couple. Once their question is answered, the nurse should encourage them to speak with their health care provider about their specific plan. They can be encouraged to write their plan out and share it with the nurse at their next class once they have all the information they need and input from their health care provider. A simple birth plan can help ensure the couple's wishes are known and respected by the whole team. The plan needs to be realistic and allow for the best approach in case any complications arise.

A 52-year-old postmenopausal woman asks the nurse how frequently she should have a mammogram. How should the nurse respond? "Once a woman reaches 50, she should have a mammogram yearly." "Yearly mammograms are advised for any women over 35." "Unless you had previous problems, every two years is best." "Your health care provider will advise you about your risks and the frequency."

"Once a woman reaches 50, she should have a mammogram yearly." Rationale: The American Cancer Society recommends a screening mammogram by age 40, every one to two years for women 40 to 49, and every year from age 50 onward. If there are family or personal health risks, other more frequent and additional assessments may be recommended.

A nurse is performing a health history on a 59-year-old client. The client tells the nurse they have been experiencing increasing back pain and have noticed a decrease in height. How will the nurse educate the client on the prevention of further problems? "Take a daily multivitamin with your meals." "Perform weightbearing activities at least 3 to 5 times a week." "Be sure to consume plenty of legumes in your diet." "Avoid sun exposure as much as possible."

"Perform weightbearing activities at least 3 to 5 times a week." Rationale: The client's physical manifestations are consistent with the development of osteoporosis. To increase bone strength and muscular support, weight bearing exercises are recommended at least 3 to 5 times a week. Most multivitamins do not provide the necessary amount of recommended daily calcium to support bone health. Calcium-rich foods are recommended to increase bone density. Legumes are rich in iron. Vitamin D supports bone health. Sun exposure supplies a non-food source of Vitamin D.

A nurse is assessing the health status of several clients at a community health event. The nurse should conduct a mental status examination on which clients? Clients who report memory lapses. Clients who display restlessness. All clients participating in the event Clients with obvious signs of depression.

All clients participating in the event Rationale: A mental status assessment is a critical part of baseline information and should be a part of every screening. This assessment serves as a screening tool for the nurse to assess for mental status abnormalities. The tool evaluates the client's behavioral and cognitive functioning.

The nurse is caring for a client who asks the nurse to explain the basic ideas of homeopathic medicine. Which of the following responses by the nurse would best explain the approach of such remedies? Boost the immune system Destroy organisms causing disease Increase bodily energy Maintain fluid balance

Boost the immune system Rationale: Homeopathic medicine treats clients with minute doses of plant, mineral or animal substances that provide a gentle stimulus to the body's own defenses.

The nurse is caring for a client who states that they have recently become a single parent. Which question by the nurse is appropriate to assess how this family structure change has affected the client? "Are tasks more difficult now that you don't have help?" "When did you and your partner separate?" "How many children live with you currently?" "Where did your partner go after you separated?"

"Are tasks more difficult now that you don't have help?" Rationale: Asking the client to talk about hardships related to a family system change such as a divorce/separation is appropriate to evaluate how the transition to being a single parent has affected them. All the other responses do not assess the impact on the client.

The nurse is caring for a client who has recently undergone an above the knee amputation. Which question by the nurse is appropriate to evaluate the client's feelings about their body image? "Are you worried about losing your mobility?" "Has your family come to visit you since you had the surgery?" "Do you plan to utilize a prosthetic leg after you have healed?" "Does the loss of your leg change how you feel about yourself?"

"Does the loss of your leg change how you feel about yourself?" Rationale: Significant physical changes, such as an amputation, may affect the client's body image. Asking the client to share their feelings about self-esteem or perceived body image provides insight into how the change has impacted the client. While mobility and prosthetic use may be important questions to ask, they do not address body image concerns. Family visitation does help to support the client throughout a stressful event but does not directly affect the client's body image.

The nurse is educating a pregnant client on role transition and mental health in the postpartum period. Which of the following statements should the nurse include in the teaching? "Psychosis is the most common mood disorder after delivery." "Postpartum depression can be diagnosed as early as 24 hours after delivery." "Postpartum mood disorders and fatigue only occur in mothers." "Emotional lability is common within the first few days after delivery."

"Emotional lability is common within the first few days after delivery." Rationale: Postpartum "blues" is common following childbirth and typically peaks around day 4-5 and often resolves around day 10 after delivery. Postpartum blues include symptoms such as emotional lability, anxiety, fatigue, and sadness. Postpartum depression symptoms are like those of the baby "blues" but last more than two weeks. Mood disorders can also occur in partners but are less common. Psychosis occurs only in 1-2 women per 1000 births.

The nurse is educating older adult clients at a health fair. Which of the following statements should be included in the teaching? "Exercise is important to keep your bones healthy." "Most older adults would benefit from weight loss diets." "Depression is a normal part of the aging process." "Group activities increase the risk of falling."

"Exercise is important to keep your bones healthy." Rationale: Regular exercise is an important part of musculoskeletal health in the older adult population, and this should be included in the client education. Weight-loss diets are not recommended in most cases. Depression is an abnormal finding for any age group. Group activities are beneficial to prevent social isolation; they do not increase the risk of falls.

The nurse is providing discharge instructions to a client about formula feeding a 2-day-old baby. Which of the following statements should be included in the teaching? "The baby should drink about 50 ounces of milk a day." "Save any leftover formula for the next feeding." "Feed your baby at least every 4 hours." "You can prop the bottle up with a blanket or a pillow."

"Feed your baby at least every 4 hours." Rationale: Bottle-fed infants should be fed at least every four hours for the first two weeks of life. Fifty ounces (1500 mL) is excessive intake. On average, a week-old infant drinks 3-5 ounces (90-150 mL) per day. Any leftover formula should be discarded after a feeding, and propping up a bottle for feeding is a dangerous technique that increases the newborn's risk of aspiration.

The nurse is caring for a 2-year-old toddler with a neural tube defect. The mother of the child asks the nurse, "What can I do to decrease the chances of having another baby with a neural tube defect?" Which of the following responses would be the most appropriate response by the nurse to the client's mother? "Multivitamins are recommended during pregnancy. "Folic acid should be taken before and after conception." "A well-balanced diet promotes normal fetal development." "An increase in iron improves the health of the mother and fetus."

"Folic acid should be taken before and after conception." Rationale: The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements prior to getting pregnant and during pregnancy. Evidence-based practice validates that increased amounts of folic acid prevents neural tube defects such as spina bifida.

The nurse is assessing a female adolescent client for her reaction to expected body-image changes during a wellness visit. Which of the following client statements may indicate the client is having difficulty accepting the changes? "I want to start shaving my legs because I hear it is hard to keep up with it once you do it." "I am glad I started wearing a bra already since the boys like to snap the bra straps and I think one of them likes me." "I really want my best friend to get her period soon, so we can talk about it together." "I am so much taller than all the boys in our class that I doubt anyone will ask me to go to the end-of-year dance."

"I am so much taller than all the boys in our class that I doubt anyone will ask me to go to the end-of-year dance." Rationale: The adolescent developmental stage is identity versus role confusion, and to achieve this development, it is important that the nurse assesses if the client is accepting her changed body image as it occurs. The client indicates negative feelings about being taller than all the boys and possibly being left out of an activity because of it. Admitting feelings about shaving legs, attention received from wearing a bra, and having something in common with a best friend are indications that the client is accepting of expected changes that are occurring or will occur.

A nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 am and ending at 10:01 am. Another begins at 10:15 am. A third contraction begins at 10:30 am. What is the frequency of the contractions? 14 minutes 10 minutes 9 minutes 15 minutes

15 minutes Rationale: Frequency is the time from the beginning of one contraction to the beginning of the next contraction.

The nurse is screening clients for cancer risk factors at a community event. Which of the following clients has an increased risk of cancer due to non-modifiable risk factors? A client who has a family history of breast malignancies A client who smokes cigarettes A client who has an elevated body mass index A client who has a sedentary career

A client who has a family history of breast malignancies Rationale: A non-modifiable risk factor is a factor that increases the risk of disease/illness that the client cannot change (family history, race, etc.). All incorrect responses are modifiable risk factors of cancer (things that the client has control of and can be changed).

The client is in her first trimester of pregnancy. Which developmental task should the client accomplish during this stage of pregnancy? Addressing fears related to giving birth Accepting the pregnancy Accepting the loss of physical intimacy Viewing the fetus as a separate and unique being

Accepting the pregnancy Rationale: During the first trimester, the developmental focus is toward accepting the pregnancy and adjusting to pregnancy-related physical changes and discomforts. During the first and third trimesters, the client may become introspective, focusing on herself and the health of her baby. The client can maintain physical intimacy with her partner if she wishes, including sexual intercourse. Looking at the fetus as a separate being and overcoming fears related to giving birth begins in the second or third trimester.

The nurse is teaching a group of adolescents about sexually-transmitted infections. Which should the nurse emphasize as the most common sexually-transmitted infection? Herpes Human immunodeficiency virus (HIV) Gonorrhea Chlamydia

Chlamydia Rationale: Chlamydia is the most frequently reported bacterial sexually-transmitted infection in the United States. This infection has subtle symptoms so an infected person is less likely to seek medical attention and more likely to unknowingly infect others. Prevention is similar to safe sex practices taught to prevent any sexually-transmitted infection including abstinence and the use of condoms during intercourse.

The nurse is educating a client who is 34 weeks pregnant and has a history of hypertension about prenatal complications. Which finding should the nurse instruct the client to report immediately to the healthcare provider? Headache that does not go away Pedal edema: 1+, bilaterally Shortness of breath on exertion Occasional mild contractions

Headache that does not go away Rationale: Preventing complications related to preeclampsia requires the use of assessment, advocacy, and counseling skills. Client's with gestational hypertension should be instructed to perform self-monitoring and be educated on the signs of worsening preeclampsia including visual changes, severe headaches, bleeding or bruising, and epigastric pain. All other options are expected findings in the third trimester of pregnancy.

The nurse is caring for a client who is 28 weeks pregnant. Which of the following physical changes should the nurse identify as an expected finding? Facial edema Kyphosis Lower extremity erythema Linea nigra

Linea nigra Rationale: Extra integumentary pigmentation during pregnancy can create a darkened vertical line down the abdomen called linea nigra. Facial edema is an abnormal finding that requires follow-up from the healthcare provider. Lordosis is expected in pregnancy, kyphosis is not, and erythema of the lower extremities is an abnormal finding.

While caring for a postpartum client during the first hour after a non-complicated vaginal delivery, the nurse determines that the uterus is boggy, and there is a moderate amount of vaginal bleeding. Which action should the nurse take first? Check for any abnormal vital signs Massage the fundus until firm Provide perineal care Document the findings

Massage the fundus until firm Rationale: A boggy uterus means that the uterine muscle is not contracting firmly and is more flaccid than desired. This is also referred to as "uterine atony." A flaccid uterus can lead to prolonged bleeding and hemorrhage; therefore, the first action of the nurse should be to massage the fundus to promote good uterine tone and prevent postpartum hemorrhage.

A pregnant client asks the nurse when her expected delivery date will be. The client tells the nurse her last menstrual period was January 28th. What date will the nurse tell the client is the expected delivery? November 4th October 28th December 4th November 11th

November 4th Rationale: The expected delivery date is calculated using Nagele's rule. Three months are subtracted from the last known menstrual cycle. Seven days are added to the result. For this scenario, the calculation is as follows: (January 28 - 3 months = October 28) > (October 28 + 7 days = November 4).

During the first prenatal visit at 7 weeks, the client asks when the baby will be born. The nurse responds that after identifying the first day of the client's last menstrual period, the healthcare provider will include which of the following assessments to accurately assign an estimated due date? Auscultating fetal heart sounds Performing a transvaginal ultrasound Performing a pelvic exam Utilizing the quickening method

Performing a transvaginal ultrasound Rationale: Ultrasound measurement of the embryo or fetus in the first trimester (up to and including 13 6/7 weeks of gestation) is the most accurate method to establish or confirm gestational age. As soon as data from the last menstrual period (LMP), the first accurate ultrasound examination, or both, are obtained, the gestational age and the estimated date of delivery (EDD) should be determined, discussed with the patient, and documented clearly in the medical record.

A nurse is caring for a 5-year-old child whose left leg is in skeletal traction. Which activity would be an appropriate diversional activity? Play hand-held games Throw bean bags Kick balloons with right leg Play "Simon Says"

Play hand-held games Rationale: Immobilization with traction must be maintained until bone ends are in satisfactory alignment and with adequate regrowth of the bone. Activities that increase mobility interfere with the goals of treatment.

The nurse in a pediatric office is speaking with the parents of a 3-year-old child. The parents ask the nurse about normal growth and development. The nurse knows that which finding may be indicative of abnormal childhood development? Use of four-word sentences Positive Babinski reflex Presence of all primary teeth Presence of a pincer grasp

Positive Babinski reflex Rationale: The nurse must have an adequate understanding of normal physical development in children. The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe moves upward or toward the top surface of the foot. The other toes fan out. This reflex is normal in children up to two years old. It disappears as the child gets older. A positive Babinski reflex in a 3-year-old child indicates the need for a neurological follow-up. Pincer grasp describes the ability for a child to grasp objects between their index finger and thumb and should be established by 10 months. By three years, children should have all of their primary teeth and the ability to speak in 3- to 4-word sentences.

The nurse is caring for a pregnant woman. She is currently 42 weeks pregnant. The nurse knows that which factor could result in negative outcomes for the fetus? Progressive placental insufficiency Progressive placental insufficiency Excessive fetal weight Depletion of subcutaneous fat

Progressive placental insufficiency Rationale: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia. These newborns are typically meconium stained.

The nurse is caring for a toddler who was admitted with vomiting and diarrhea but has not had any episodes for the last 4 hours. The toddler reports being thirsty and hungry. Which of the following actions should the nurse take? Provide small sips of an electrolyte drink Provide a small amount of food and drink that the toddler would like Explain that the toddler will have to wait longer before eating and drinking Administer a prescribed intravenous antiemetic

Provide small sips of an electrolyte drink Rationale: Sips of an electrolyte drink would be appropriate to help the client stay hydrated. Food should not be started until sips of liquid are tolerated. There is no need for an antiemetic if the client is not vomiting. Explaining that the toddler will have to wait to eat or drink is not appropriate since the vomiting stopped 4 hours ago; it would be okay to start sips.

The nurse is interviewing a client and notices that the client is having a difficult time answering questions. Which action by the nurse would be an appropriate environmental adjustment to make? Reducing the background noise in the room Turning off the overhead room lights Moving to stand at the entrance of the room Attempting the interview at a later time

Reducing the background noise in the room Rationale: When a client is having a hard time answering questions, it may be due to hearing difficulties, confusion, or processing disorders. Reducing the background noise ensures that the client can hear the questions without other noise distractions. Turning off the lights and moving further away from the client may create further difficulty for the client. Attempting the interview at a later time is not appropriate if an environmental change can allow for a successful assessment.

The nurse is caring for an adult client who is being treated for multiple traumatic injuries. Which of the following questions by the nurse would be appropriate to assess the client for the possibility of intimate partner violence? "Are you ever afraid of your partner?" "How many times has your partner hit you?" "Do you use illegal substances?" "Do you have any children with your intimate partner?"

"Are you ever afraid of your partner?" Rationale: When a client has obtained multiple traumatic injuries, the nurse should be concerned about the possibility of abuse and should screen the client accordingly. Asking the client if they are fearful of their partner allows the nurse to have an open conversation about the relationship dynamics. Asking how many times the partner has hit the client is assuming that abuse is occurring. Illegal substance use and the number of children do not address the nurse's concern of abuse.

The nurse is screening clients at a community center for nutritional deficits. Which of the following questions by the nurse is most appropriate? "Can you list the food items that you have eaten for the past day?" "When was the last time you visited a primary care provider?" "How old were you when you started struggling with your weight?" "Does anyone in your family experience gastrointestinal issues?"

"Can you list the food items that you have eaten for the past day?" Rationale: A 24-hour diet recall is an easy way to obtain information about a client's dietary intake. Asking questions about family history or patterns of medical treatment may be helpful in a client's nutritional assessment but do not provide the nurse with information directly related to dietary practices.

The nurse is providing discharge teaching for the parent of a 3-year-old client who has a long-leg hip spica cast. Which of the following information should the nurse include in the teaching? "Assist with feeding your child to encourage oral intake." "Provide puzzles or small building blocks to play with to help develop your child's fine motor skills." "Continue to cuddle and touch your child often on non-casted areas of the body." "Avoid moving and repositioning your child too often."

"Continue to cuddle and touch your child often on non-casted areas of the body." Rationale: Children at this age thrive on being touched. The parent of a child in a large body cast may need a demonstration of how to cuddle or move the child in this type of cast. Remind the parent that the child can and should be touched often on areas that are not covered by the cast. The child at age three wants to be independent and feed themself. Encouraging independence and offering finger foods that the child can handle themselves would encourage oral intake more than the child being fed; the cast should be protected from dropped or spilled food. The parents should be taught how to easily move and reposition the child. Carrying the child or using a toy wagon can be easily taught to the parents to avoid the child feeling isolated in one place of the home. Small toys should be avoided with this type of cast because they can fall into the cast and cause skin integrity issues.

A community health nurse is conducting a class on nutritional counseling. A client asks the nurse the best way to prevent heart disease. What will the nurse include in the teaching plan? "When eating poultry, choose meats such as duck." "Eat oily fish, such as salmon or trout." "Dairy should be eliminated from the diet." "Use white rice when cooking with grains."

"Eat oily fish, such as salmon or trout." Rationale: Fatty fish, such as salmon, trout, and herring, contain high amounts of omega-3 fatty acids, which can increase high density lipoprotein (HDL) cholesterol levels. Duck and goose are high in fat content. Chicken and turkey are a healthier poultry alternative. Dairy does not have to be eliminated from the diet. Low-fat or fat-free options are acceptable. Brown rice is recommended, as opposed to white rice, because it contains higher amounts of nutrients in the grain.

The nurse is admitting a 2-year-old child who has had a seizure. Which of the following statements by the child's parents would be the most important in the determination of the etiology of the seizure? "His naps have been getting longer and longer." "He seems to be constipated." "He's had an ear infection for two days." "Red meat has been his favorite food lately."

"He's had an ear infection for two days." Rationale: Up to 10% of all children experience at least one seizure during their childhood. Contributing factors to seizures in children, commonly in the first two years of life, include age, infections associated with febrile seizures, fatigue, not eating properly, and excessive fluid intake or fluid retention. Febrile seizures are the most common type of seizure. Young children who develop otitis media can develop high temperatures. The consumption of red meat and constipation are not considered triggers for seizure activity. Although longer naps may occur in children who have an infection, longer naps do not routinely precede a seizure.

The nurse provides instructions to a new mother on the proper techniques for breastfeeding her infant. Which statement by the mother indicates a need for additional instruction? "The baby should latch onto the nipple and areola areas." "There may be times that I will need to manually express milk." "I should position my baby completely facing me with my baby's mouth in front of my nipple." "I can switch to a bottle if I need to take a break from breast-feeding."

"I can switch to a bottle if I need to take a break from breast-feeding." Rationale: Babies adapt more quickly to the breast when they are not confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby's suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breastfeeding.

The nurse is caring for an older adult client in the acute care setting. Which of the following statements by the client indicates that they may be experiencing social isolation? "I hate that I have gotten so old." "I don't want people to see me in this condition." "I wish I could walk up the stairs without getting out of breath." "I depend on my family members for so much."

"I don't want people to see me in this condition." Rationale: In order to identify a client at risk for social isolation, the nurse needs to assess the client's social network, access to transportation, and desire to interact with people. In this case, the client is stating that they do not want people to see them, thus indicating that they want to avoid interaction.

The nurse is teaching a group of clients about reducing the risk of skin cancer. Which statement by the client indicates the need for additional teaching? "I wear sunglasses with ultraviolet protective lenses." "I found a sunscreen with a sun protective factor of 30." "I only tan in the controlled setting of a tanning booth." "I make sure to come inside between noon and 2 pm."

"I only tan in the controlled setting of a tanning booth." Rationale: Tanning booths and sun lamps are no safer than the natural sun in terms of cellular damage and potential for developing skin cancer. The other self-help measures have positive effects on reducing the chance of damage from ultraviolet rays.

The nurse is interviewing a client to obtain a health history. Which statement by the client indicates an increased risk for developing colorectal cancer? "I take a vitamin D supplement every day." "I have been a vegetarian for 6 months." "I was diagnosed with Crohn's disease last year." "I stopped drinking alcohol about 10 years ago."

"I was diagnosed with Crohn's disease last year." Rationale: Inflammatory bowel disease (Crohn's, ulcerative colitis, etc.) increases the risk of colorectal cancers. Diets high in fruits and vegetables and little to no alcohol intake decrease the risk of colorectal cancers. Low levels of vitamin D increase the risk, but if the client takes a supplement every day, they will likely not have a vitamin D deficiency.

The nurse is following up with a primipara client who enrolled in a maternal-infant health program. Which statement made by the client demonstrates the program was effective? "I place my baby forward-facing in the back seat of the car." "I throw away my excess breast milk since I can also give my baby formula." "I lay my baby on their side every night before bed." "I will take my baby to get several vaccines when they turn 2 months old."

"I will take my baby to get several vaccines when they turn 2 months old." Rationale: Maternal, infant, and child health programs focus on infant care and postpartum health. Immunizations are part of health promotion. At 2 months, infants will receive between 5 and 6 scheduled vaccines. Infants should be placed rear-facing in a car seat until the age of 2 to 4. Breast milk provides natural antibodies and should be encouraged over formula if the client is able to breastfeed or produce breastmilk. Babies should be laid on their backs to prevent accidental suffocation.

During a clinic visit, a 49-year-old female client tells the nurse, "I think I am beginning to experience hot flashes." The client asks the nurse what she can do to minimize menopausal symptoms. Which of the following is an appropriate nursing response? "Incorporate yoga into your exercise routine." "Long-term use of soy supplements can help you with your symptoms." "Eat raw flaxseed with plenty of water." "Acupuncture can provide the same benefits as hormone therapy."

"Incorporate yoga into your exercise routine." Rationale: Research has shown that yoga and other meditation-based exercises can reduce the frequency and intensity of menopausal symptoms, such as hot flashes, joint pain, and mood disturbances. Long-term use of soy supplements has been associated with thickening of the lining of the uterus. There are conflicting studies on whether flaxseed is effective in lowering menopausal symptoms. Additionally, raw flaxseed can contain potentially toxic ingredients. Research has shown that acupuncture is less effective than hormone therapy. Additionally, acupuncture can cause infections and tissue damage if not performed correctly.

During an assessment interview, a middle-age client verbalizes experiencing increasing stress at work. The client asks the nurse what they can do to help prevent complications from stress. What advice will the nurse give the client? "Inhale through your nose and exhale through your mouth as deeply as possible several times a day." Correct Answer (Blank) "It might be helpful to reconsider your career choice at this time." "Your work situation will be short-lived, so you shouldn't experience complications." "Incorporate kava into your diet to help with the anxiety."

"Inhale through your nose and exhale through your mouth as deeply as possible several times a day." Rationale: Relaxation techniques help develop awareness and can help prevent the negative effects of stress. The nurse should suggest mini-relaxation techniques throughout the day. Advising the client to reconsider their career choice is not within a nurse's scope of practice. Telling the client their work situation will be short-lived is an assumption and does not address the client's concern. Kava is an herbal treatment not approved by the Food and Drug Administration and can cause liver damage if not monitored properly.

The nurse is assessing an adolescent client for psychosocial concerns after a recent parental divorce. Which of the following statements by the client indicates that the divorce has had a negative impact on their mental health? "The divorce has cost my family a ton of money." "Living in two different houses is challenging." "I hope that my parents can be happy again." "It's my fault that they got divorced."

"It's my fault that they got divorced." Rationale: When a child voices that they feel to blame for a situation that is out of their control (such as a divorce or the death of a family member), it indicates to the nurse that the event had a significant negative impact on the child. All the other responses do not indicate a mental health concern.

The nurse is teaching a parenting class to clients at a community center. Which information should be included in the education related to infant growth and development? "Most babies gain about 2 pounds every month until they reach 6 months old." "Your baby should double birth height by their first birthday." "Babies don't start to hold their head up until about 4 months of age." "You should see a doctor if your baby is not able to walk by 11 months old."

"Most babies gain about 2 pounds every month until they reach 6 months old." Rationale: In the first six months of life, infants gain about 2 pounds per month; weight gain then slows to about 1 pound per month for months 6-12. Height at one year old is typically 1.5 times the infant's birth height. Infants begin holding their head up around 2 months of age, and while some infants may walk at 11 months old, it is not a cause for concern if the baby is not walking at this age.

The nurse is obtaining a health history from a male client for risk factors of prostate cancer. Which of the following client statements about diet would increase the client's risk? "I maintain a strict vegetarian diet." "My favorite proteins are steak and ice cream." "My family says all I eat is carbohydrates." "I like to eat pizza and carbonated beverages."

"My favorite proteins are steak and ice cream." Rationale: Diet can increase the risk of prostate cancer in men. Excessive amounts of red meat or dairy products that are high in fat increase the risk. Vegetarian diets, carbohydrates, pizza, and carbonated beverages do not increase the risk for prostate cancer.

The nurse is educating an adolescent client about sexual health. Which of the following statements by the client indicates the need for further education? "Only gay men can get HIV or AIDS." "I should be cautious with who I have sex with." "Sexually transmitted infections (STIs) can be transmitted through any sexual contact." "Having multiple partners can be risky."

"Only gay men can get HIV or AIDS." HIV and AIDS can be transmitted to anyone regardless of race, age, or sexual preference. Being cautious about sexual contact and knowing that multiple partners increase risk are appropriate. STIs can be transmitted through any sexual contact, so this does not indicate the need for further education, as this is a true statement.

The nurse is caring for a male client admitted with a diagnosis of a spinal cord injury. The client asks the nurse how the injury will affect his ability to have sex. Which is the best response by the nurse? "There are drugs to help with achieving an erection." "Sexual intercourse may be possible." "Sexual functioning will not be impaired at all." "Normal sexual function is not possible."

"Sexual intercourse may be possible." Rationale: During the acute phase of a spinal cord injury (SCI), the long-term effects are not predictable and depend on the body's healing. Sexual function, or the ability to have sex after an SCI, will depend on multiple factors, including the severity of the injury and the age and health of the client. Sexual intercourse might be possible. The nurse should refrain from making absolute statements that are not founded on facts and considered outside of the nurse's scope of practice. Drugs used for erectile dysfunction are not typically effective with an SCI.

A new parent calls the pediatrics office to speak to the nurse. The parent reports that their 4-week-old infant sleeps almost 16 hours a day and the parent expresses concern that there might be something wrong with their child. How should the nurse respond? "Please make an appointment for the baby to be seen by the pediatrician." "Tell me more about other behaviors of the baby." "Why do you think that your baby is abnormal?" "That is normal for a baby that age. You do not need to worry."

"Tell me more about other behaviors of the baby." Rationale: Using therapeutic communication techniques and following the nursing process, the nurse should gather more information from the parent about their baby, in order to be able to determine if the child should be seen in the office. Although sleeping 16 hours a day is within the normal range for a 4-week-old infant, the nurse should encourage the parent to describe other behaviors such a feeding and how the baby acts when awake."'Why" questions or dismissing the parent's concern are nontherapeutic.

The nurse is interviewing the parent of a 12-month-old infant at a well visit. Which statement by the parent indicates the need for further assessment of the child's development? "The baby just recently started crawling." "The baby is starting to say a few different words." "The baby loves to play with cups, pots, and pans." "The baby can pick up small objects with the first finger and thumb."

"The baby just recently started crawling." Rationale: Crawling is an expected developmental milestone for a 9-month-old child. It is concerning that at 12 months old the baby just started to crawl, and this requires additional assessment. At 12 months old, a child is expected to say at least two words, play with pots/pans, and stack toys. The pincer grasp should be well developed by 12 months of age.

The nurse is interviewing the parent of a 3-day-old client at an outpatient well visit. Which of the following statements by the parent creates concern for the wellbeing of the infant? "There is no one to watch the baby while I work." "My family has to share one car." "There is a history of drug addiction in my family." "The baby only sleeps for three hours at a time."

"There is no one to watch the baby while I work." Rationale: The statement that the parent has no one to watch the infant while they work is concerning because the parent must choose between leaving the baby alone or losing their job. While this lack of support doesn't directly harm the infant, it can lead to an unsafe situation. Sharing one car and newborn sleep cycles are not safety concerns. Having a family history of substance abuse warrants further assessment, but this statement does not indicate that someone who is abusing substances is in contact with the infant.

The nurse in a pediatric clinic is talking to the mother of a 1-month-old baby who is being breastfed. The mother is concerned about the baby's stools and reports that the stools are a lumpy yellow liquid. How should the nurse respond? "If you eat more fiber, it will pass through your milk and harden the stools." "The stools should be more of a brown color and formed by now." "Those stools are normal for a baby who is breastfed." "You should supplement breastfeeding with formula to thicken the stools."

"Those stools are normal for a baby who is breastfed." Rationale: Breastfed infants who are 4 to 6 weeks old typically have stools that are frequent and yellow to gold in color. The texture is often described as soft to a thick, seedy, or curdy liquid. The mother is describing a normal finding for a breastfed infant. The other responses are incorrect or inappropriate for this infant.

The homecare nurse is conducting a complete assessment during the first visit with a new client and the primary caregiver. Which of the following statements by the caregiver should the nurse identify as the priority concern? "We eat two meals each day." "It is difficult to get to all of our appointments." "We buy the prescriptions we can afford." "We have both been feeling a little down lately."

"We buy the prescriptions we can afford." Rationale: Caregivers with higher financial burdens are at higher risk of role strain and reduced quality of life. The financial costs of caregiving may include healthcare costs of the care recipient and caregiver, adaptations and devices in the home, hired assistance for activities of daily living (e.g., driving, house cleaning), and prescriptions. Cost-related medication nonadherence may occur in both the client and the family, as family members may give up employment to provide care.

the nurse is caring for a client who states, "I know that I don't eat a healthy diet." Which of the following questions by the nurse is appropriate to gain further information about the client's nutritional choices? "How much do you weigh currently?" "Do you follow a 2,000 calorie diet?" "What is your favorite kind of food?" "What foods have you eaten in the last 24 hours?"

"What foods have you eaten in the last 24 hours?" Rationale: Asking the client to provide examples of what foods they have eaten in the last 24 hours provides insight into the client's dietary choices. Asking about the client's favorite foods or their current weight does not assess the client's lifestyle practices. While asking the client if they follow a 2,000 calorie diet does address intake, it does not adequately assess the types of food that they eat.

The nurse is performing a home visit of a client who lives within a blended family. Which of the following questions by the nurse is appropriate to assess roles within the family unit? "How many family members own a vehicle?" "Which of the children is the oldest?" "Does anyone in the home use tobacco?" "Who is responsible for taking the children to school?"

"Who is responsible for taking the children to school?" Rationale: Taking the children to school and other activities is a large responsibility within a family. The nurse should ask this question and other similar questions to determine which family member is responsible for certain tasks. While the number of vehicles and tobacco use are important to assess, they do not affect the roles within family. The ages of the children do not directly affect the family function.

A client with newly diagnosed diabetes type 2 is receiving information on follow-up care. The client states, "There is so much I have to learn about this illness." What is an appropriate response by the nurse? "Be sure to write down all the questions you have about diabetes before your next visit." "You will be referred to a diabetes educator for further management." "Make sure to take all of your scheduled medications to prevent complications from diabetes." "It is important for you to research information about diabetes thoroughly."

"You will be referred to a diabetes educator for further management." Rationale: Diabetes is a complex illness. Clients with newly diagnosed diabetes will benefit from a referral to a diabetes educator for comprehensive education on the illness. The client's concerns should be addressed as soon as possible to prevent complications. Medications are only one factor to help manage the complex disease process. Newly diagnosed clients require structured guidance for managing their disease process.

The nurse is screening a client who had surgery for diabetes mellitus, type 2, and the client asks, "Why would you think I have diabetes? I feel fine and no one in my family has diabetes." Which of the following responses would explain the reason for the nurse to screen the client? "When I tested your arterial blood gases, your pH level was decreased." "Your urine test showed that your BUN and creatinine levels were severely decreased." "When I tested your urine, I noticed there were ketones present." "Your laboratory results show an increase in serum osmolality and glucose levels."

"Your laboratory results show an increase in serum osmolality and glucose levels." Rationale: Diabetes mellitus (DM), type 2, can result in hyperglycemic hyperosmolar syndrome (HHS) when the client is unaware that they have diabetes. HHS is a metabolic disorder of type 2 DM resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin. Laboratory results would show an increase in serum osmolality and blood glucose levels over 600 mg/dL. BUN and creatinine levels would be elevated. Ketones and a decreased arterial pH level would be present in DKA, which is a complication of DM, type 1.

During an annual physical, a 55-year-old client tells the nurse, "I have noticed an increase in belching." How does the nurse explain gastrointestinal changes to the client? "Your muscle tone decreases as you get older, and movement of food slows down." "Your stomach produces more enzymes as you age and causes indigestion." "Your metabolism decreases and causes you to eat more food." "Your stomach capacity decreases, and food backs up."

"Your muscle tone decreases as you get older, and movement of food slows down." Rationale: Aging causes biological changes in the gastrointestinal system and result in decreased metabolism, decreased intestinal tone, and decreased gastric enzyme production. The decrease in gastrointestinal activity can result in increased acid indigestion and belching. The stomach produces fewer digestive enzymes with aging. A decrease in metabolism requires less caloric intake, not more. Stomach capacity is influenced by the decrease in elasticity, not a physical reduction in size.

A nurse in a well-child clinic examines many children on a daily basis. Which of these toddlers requires further follow-up? A 20 month-old only using 2 and 3 word sentences A 13 month-old unable to walk A 24 month-old who cries during examination A 30 month-old only drinking from a sippy cup

A 30 month-old only drinking from a sippy cup Rationale: The toddler should be able to drink from an open cup between 16 and 17 months, thus should not be drinking only from a sippy cup. It is not unusual for toddlers to cry during exams. The toddler is usually walking by 18 months old. The toddler will have the language development for 2 to 3 word sentences by age 2.

The nurse working at a community health clinic is screening clients for risk factors of hypertension. Which client is at highest risk for developing hypertension? A 60-year-old Asian American male. A 65-year-old African American male. A 40-year-old Caucasian female. A 55-year-old Hispanic female.

A 65-year-old African American male. Rationale: The incidence of hypertension (HTN) is greater among African Americans than other groups in the United States. Males have higher rates of HTN than females. Increased age also increases the risk for developing HTN. Therefore, the client with all of these risk factors is at highest risk for developing hypertension.

A nurse is performing psychosocial assessments on several clients in an obstetric clinic. Based on the history obtained, which client is at risk for impaired coping during pregnancy? A client who verbalizes feeling irritable and has lost sexual desire towards her partner A client who lives in a multi-generational household and believes pregnancy is a transitional period of illness A client with a history of sexual abuse who is highly involved in her church community A client with a history of depression who is married and has two other children

A client who lives in a multi-generational household and believes pregnancy is a transitional period of illness Rationale: Hormonal changes during pregnancy and cultural norms can decrease the client's ability to cope. Strong social support from family, friends, and community members can assist the client during overwhelming mood swings. A client who believes pregnancy is an illness will have difficulty coping and adjusting to her new lifestyle. Cultural beliefs should be assessed, and unsafe practices should be further evaluated. Mood swings and loss of sexual desire are common responses to hormonal changes during pregnancy. The nurse should encourage stress relieving strategies. While previous history of sexual assault may cause anxiety during the birthing process, a strong social support system can help the client cope. Although the client has a history of depression, the client has a support system as indicated by a partner and children.

A parent asks the school nurse how to eliminate lice from a child's head. Which statement is the appropriate response by the nurse? Apply a pediculicide as directed Wash the child's linen and clothing in a bleach solution Cut the child's hair short to remove the nits Apply warm soaks to the head twice daily

Apply a pediculicide as directed Rationale: Treatment of head lice usually consists of an application of a pediculicide. Parents should be sure to follow the product directions. It is important that parents understand that no product is 100% ovicidal and, consequently, some nits will survive. Parents will need to use a nit comb to remove any surviving nits that cling to the hair shaft. In order to avoid reinfestation, bed linens must be washed in hot water and dried in the dryer; toys and objects that cannot be washed should be bagged.

The nurse is assessing the vision of a client at a well visit. Which of the following actions by the nurse would be appropriate? Instructing the client to blink rapidly Shining a light into both of the client's pupils Asking the client to identify letters on a chart Palpating the client's orbital structures

Asking the client to identify letters on a chart Rationale: In order to assess a client's vision, the nurse should ask the client to identify letters, numbers, or symbols on a chart, such as the Snellen chart or Jaeger card. While shining a light into the client's pupil is a common part of an eye assessment, this does not directly test vision. Asking the client to blink rapidly and palpating the orbital structures do not assess vision.

Which of these activities are examples of primary prevention activities? Select all that apply. Rehabilitation Cholesterol screening Breast self-exam An exercise class Car seat installation education Vaccination

An exercise class Car seat installation education Vaccination Rationale: Engaging in an exercise class, correctly installing a child safety or car seat and getting vaccinations are considered primary prevention activities. Rehabilitation falls under tertiary prevention. Cholesterol screening and breast self-exam are secondary prevention interventions.

The nurse is interviewing a client during her first trimester of pregnancy. During the interview, the client tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which nursing intervention is most appropriate at this time? Counsel the client to consent to testing for human immunodeficiency virus and sexually transmitted infections Discuss the risk of cervical cancer Ask the client for the name of each sexual partner Refer the client to a family planning clinic

Counsel the client to consent to testing for human immunodeficiency virus and sexually transmitted infections Rationale: The client's behavior places her at high risk for human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). While the client is voicing concern about not knowing who the father of the child is, the nursing priority is the safety and health of the mother and baby; therefore, the most appropriate intervention is for the nurse to provide information and counsel the woman to consent to HIV and STI testing. After the appropriate testing has occurred, the nurse can discuss health risks and methods to determine the paternity of the child. Referring the client to a family planning clinic, or requesting the names of sexual partners is not appropriate.

The mother of a 2-month-old child calls the nurse at a pediatrician's office two days after the child received the DTaP, inactivated polio vaccine (IPV), hepatitis B vaccine, and haemophilus influenzae type B (HIB) immunizations. The mother reports that the baby feels warm, has cried inconsolably for three hours, and has had several shaking spells. Which immunization would the nurse expect to be responsible for these findings? DTaP IPV HIB Hepatitis B

DTaP Rationale: DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough). The majority of reactions described in this question occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose, as well as signs of encephalopathy within seven days of the immunization.

The nurse is caring for a client who uses condoms for family planning. Which of the following would be considered an expected outcome for this client's plan of care? The client will not have a herpes outbreak within the next year. The client will not become pregnant within the next year. The client will have fewer sexual partners over the next year. The client will experience no hormonal side effects over the next year.

The client will not become pregnant within the next year. Rationale: Expected outcomes for contraception not only include the method's effectiveness but also correct use of the method and satisfaction with the method. In this case, not becoming pregnant is an expected outcome. Condoms do not directly affect the other outcomes listed.

The nurse is caring for a client with moderate Alzheimer's disease who is admitted for evaluation of a pressure ulcer. The spouse of the client appears distressed and voices concern about continuing to care for the client at home. Which action is most appropriate at this time? Encourage the spouse to describe their concerns Offer information about the local Alzheimer's Association chapter Request a sedative prescription for the client Provide resources about respite care

Encourage the spouse to describe their concerns Rationale: Alzheimer's disease is a progressive neurological disease leading to dependence with most activities of daily living, incontinence, speech, and emotional lability. It is very challenging for caregivers to take care of those clients; therefore, it is most appropriate at this time to address the spouse's concern. This can be achieved by encouraging the spouse to talk about challenges they are experiencing. The pressure ulcer may be evidence that the spouse can no longer care for the client without additional resources at home. Based on the information gained, the nurse can then decide on what action to take next.

A nurse is caring for a client who is 4 days postpartum. Upon assessment, the nurse notes dark, purulent lochia on the perineal pad. The nurse suspects which postpartum complication? Mastitis Endometritis Urinary tract infection (UTI) Retained placenta

Endometritis Rationale: Endometritis is the most common type of postpartum uterine infection. Endometritis is an infection of the uterine lining. Physical findings include dark, profuse, purulent, or malodorous lochia, fever, and uterine tenderness. Mastitis is an enlargement of the axillary lymph nodes. Physical findings include tender, swollen, and painful breasts. UTIs are common postpartum infections. However, the physical findings include urgency and frequency of urination, fever, and pelvic discomfort. A retained placenta prevents the uterus from contracting and can result in uterine atony. Physical findings include lochia rubra and excessive bleeding.

A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be an initial action by the nurse? Discuss the appropriate use of "time-out" Explain that this behavior is expected Explain that the child needs extra attention Arrange to change client care assignments

Explain that this behavior is expected Rationale: During normal development, fear of strangers becomes prominent and begins around age 6 to 8 months-old. Such behaviors include clinging to parent, crying and turning away from the stranger. These fears and behaviors extend into the toddler period. In the toddler period, separation anxiety is at its peak. As the child ages the behavior has a tendency to wane.

The nurse is assessing a school-aged child. Which of the following actions by the nurse is appropriate? Explaining each part of the assessment to the child Using an adult sized blood pressure cuff on the child's leg Avoiding the abdominal assessment for privacy Addressing the child's parent for all interview questions

Explaining each part of the assessment to the child Rationale: The school-aged child is often curious and may be intimidated by medical equipment; therefore, explaining all actions in simple terms helps to avoid anxiety and allows the child to see the interaction as a learning experience. A pediatric blood pressure cuff should be used unless the child is measured and requires adult size. All systems should be assessed, and the child should be addressed for most questions.

A mother has been exclusively breastfeeding her 6-month-old. She requests information about meeting the nutritional needs of her infant. What information should the nurse provide? Decrease the number of times per day the infant receives breast milk Offer finger foods to encourage self-feeding Include a variety of food choices with meals and snacks Gradually add iron-rich pureed meat and cereal to the infant's diet

Gradually add iron-rich pureed meat and cereal to the infant's diet Rationale: Pureed iron-rich meat, meat alternatives, and/or iron-fortified cereal are the first complementary foods that are introduced to infants. The mother will continue to breastfeed while introducing these foods. The next food transition is strained or mashed foods, and then finger foods may be introduced. By the age of 1 year, children should have a regular schedule of meals and snacks. Breastfeeding may continue during all these transitions.

The nurse assesses delayed gross motor development in a 3-year-old child. The inability of the child to do which action confirms this finding? Catch a ball Stand on one foot Ride a bicycle Skip on alternate feet

Stand on one foot Rationale: At this age, gross motor development allows a child to balance on one foot.

The nurse is performing an initial assessment of a client in the emergency department. The client states, "I feel like I can't breathe." Which of the following assessments should the nurse complete first? Obtaining the client's oxygen saturation Auscultating the client's breath sounds Palpating the client's carotid pulse Inspecting the client's extremities

Obtaining the client's oxygen saturation Rationale: When a client is seeking care for a significant respiratory concern, the nurse should prioritize assessments to determine the acuity of the client's concern. Breath sounds, extremities, and pulses should be assessed, but if the client's oxygen saturation is very low, other interventions may take priority.

A nurse is caring for a client who is pregnant and is having a nonstress test performed. The fetal heart rate (FHR) is between 130 and 150 beats/min, and there has been no fetal movement for 15 minutes. Which of the following actions should the nurse perform? Prepare to provide a report to the hospital nursing staff Continue to monitor the client with no intervention Offer the client a snack of orange juice and crackers Place the patient into supine position

Offer the client a snack of orange juice and crackers Rationale: The NST involves 20 minutes of monitoring the FHR while assessing the number, amplitude, and duration of accelerations that usually correlate with fetal movement. A normal, reactive NST indicates fetal activity as evidenced by two or more accelerations peaking at 15 bpm or more above baseline, each lasting 15 seconds or more, and all occurring within 20 minutes of beginning the test. It is important to note that an abnormal stress test is not always ominous and can occur with a sleeping fetus. The patient should tilt to the left to supine hypotensive syndrome. If a test is not reactive, FHR should be monitored for at least 40 minutes to account for the fetus sleep cycle.

The nurse is planning the sequence of a comprehensive assessment of a 16-month-old child. Which of the following assessments should be performed last? Otoscope examination Inspection of the abdomen Palpation of pulses Pupillary light reflex

Otoscope examination Rationale: In young children, it is important to sequence an assessment from least invasive to most invasive. Performing an invasive assessment (such as an otoscope exam) in the beginning of the assessment may skew the remainder of the findings if the child becomes upset.

The nurse is teaching the parents of a 2-week-old infant about the prevention of sleep-related death, such as sudden infant death syndrome (SIDS). Which intervention is the priority? Place the infant on their back to sleep Avoid placing stuffed animals near the sleeping infant Avoid exposing the infant to tobacco smoke Place the infant on a firm surface to sleep

Place the infant on their back to sleep Rationale: Sudden infant death syndrome (SIDS) is the death of a seemingly healthy infant less than one year of age that remains unexplained after a complete postmortem examination (autopsy) including an investigation of the death scene and a review of the case history to rule out abuse. The cause of SIDS is unknown; however, research suggests it may have to do with the portion of an infant's brain that controls breathing and arousal from sleep. The highest risk for SIDS is associated with sleeping in a prone position (on the stomach); other risk factors include the use of soft bedding, overheating (thermal stress), and cosleeping with an adult, especially on a sofa or noninfant bed. Since 1994, the incidence of SIDS in the United States has steadily decreased due to the Back to Sleep campaign (supine, or on their back, sleeping). Although all interventions listed are appropriate, placing the infant in a supine position/on their back to sleep is the priority.

The nurse is caring for a client diagnosed with ascites. The nurse should screen the client for signs or symptoms of which of the following possible causes? Jaundice Portal hypertension Encephalopathy Esophageal varices

Portal hypertension Rationale: Ascites is an accumulation of fluid in the peritoneal cavity commonly caused by liver damage, so the nurse should screen the client for signs and symptoms of portal hypertension. Ascites can also occur from cancer, kidney disease, and heart failure. Jaundice, esophageal varices, and encephalopathy are manifestations of liver disease, and they do not cause ascites.

The nurse is providing discharge teaching to a client who had a cesarean section. Which of the following findings should the client be instructed to report to her healthcare provider as a possible sign of infection? Gradual decrease in lochia Mild pain at the incision site Wound edges that are well approximated Purulent drainage at the incision site

Purulent drainage at the incision site Rationale: Signs and symptoms of infection may include purulent drainage, severe pain, wound edges not approximated, erythema, localized edema, increased body temperature, increased heart rate, etc. These findings should be reported to the provider. It is expected that lochia will gradually decrease over time.

A rehabilitation nurse is caring for a client who has left-sided neglect after experiencing a cerebrovascular accident (CVA). Which of the following interventions would the nurse include from the plan of care to address the client's motor and sensory deficits? Encourage the client to strengthen the unaffected side Remind the client to look to their left Have the client perform ADLs independently Assist the client to dress the unaffected side first

Remind the client to look to their left Rationale: Homonymous hemianopsia (blindness in half of the visual field in one or both eyes) may occur from stroke and may be temporary or permanent. The affected side of vision loss corresponds to the paralyzed side of the body leading to unilateral neglect. Interventions are aimed at promoting safety and independence through prompts for visual scanning (look to the affected side), encouraging the client to dress in front of a mirror to identify the affected side, and promoting the use and exercise of the affected side. Clients should work to perform ADLs independently and dress the affected side first.

The nurse is assessing a 16-month-old client at a well visit. Which of the following findings is expected for the client's developmental level? Opening a door by turning a doorknob Speaking in three-word sentences Scribbling with a crayon Walking upstairs unassisted

Scribbling with a crayon Rationale: At 15 months of age, a toddler can scribble with a pencil or crayon; therefore, this would be an expected finding for a 16-month-old. At this age, the child will only have 4-20 words in their vocabulary and cannot put together simple sentences. The motor control to turn a doorknob or walk upstairs alone is not expected until 24 months old.

The nurse is teaching a parent about the side effects of routine immunizations. Which finding should be immediately reported to the primary health care provider? Fatigue Seizure activity Localized tenderness Irritability

Seizure activity Rationale: While severe complications are rare, any seizure activity must be immediately reported; seizures can occur up to 7 days after injection. Other reactions that should be reported include crying for more than three hours, a temperature over 105°F (40.5°C) following DTaP immunization, and tender, swollen, reddened areas where the shot was given.

the nurse is educating clients in a retirement community about physical changes that occur with aging. Which of the following information should be included in the teaching? Saliva production increases with age. Cardiac output increases with age. Subcutaneous tissue increases with age. Skin dryness increases with age.

Skin dryness increases with age. Rationale: Skin dryness is a common condition in older adults. Subcutaneous tissue, cardiac output, and saliva production all decrease with age.

The nurse is assessing a 4-year-old client at a well-child visit. Which of the following findings indicate that the child's development is delayed? Inability to tie shoe laces Plays games with letters or numbers Unable to tell time on a clock Speaks in two-word sentences

Speaks in two-word sentences Rationale: At 4 years of age, the child should have a vocabulary of approximately 1,500 words and should be able to construct complete sentences. Simple two-word sentences (typically a noun and an action word) are an expected developmental milestone of the 2-year-old child. Tying shoelaces is not expected until 5 years of age, and playing games with numbers or letters is a normal finding of the 5-year-old but may begin earlier. The ability to tell time on a clock is not expected until 7-years-old.

The nurse is using the new Ballard score to perform an assessment to determine the gestational age of a newborn infant. The total score can range from -10 to 50. The infant's score is near 50. What is a reasonable interpretation of this result? The baby experienced distress during labor. The baby is post-term. The baby is premature. The baby is small for gestational age.

The baby is post-term. Rationale: Birth weight and gestational age are important indicators of a newborn's health and are used to identify any potential problems. A full-term pregnancy is usually 40 weeks. It's important to assess when gestational age is uncertain or the infant is smaller or larger than expected. The New Ballard scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments. The total score may range from -10 to 50. Premature babies have lower scores. Higher scores correlate with post-term maturity. Fetal distress during labor tends to result in lower scores.

The nurse is planning care for a client who is African American and is in active labor. The nurse should understand that the client may request which cultural practice? The client may request the use of herbs during labor. The client may refuse to have the partner present during the delivery. The client may request female family members for support. The client may request to squat during the delivery.

The client may request female family members for support. Rationale: Culturally competent care includes respecting practices that are compatible with the client's culture. The nurse should be aware of commonalities with each culture. African Americans might prefer female family members for support during labor. The use of herbs during labor and a squatting position for birth are common practices for Native Americans. Refusal of the partner's presence during labor is common in the Asian American culture.

The parents of a 7-year-old child tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? Insecurity and attention-getting are common motives. Attempts to control the family using new coping styles. The ethical sense and feelings of justice are developing. Complex thought processes help to resolve conflicts.

The ethical sense and feelings of justice are developing. Rationale: The child is developing a sense of justice and a desire to do what is right. At age 7, children are increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. This age group, 6-12 years of age, is called the school-aged group.

The nurse is collecting baseline data on a 14-month-old child during a wellness visit in the primary care provider's office. Which of the following measurement methods are correct? Select all that apply. The nurse places the tape measure around the child's head at the widest part of the frontal and occipital bones. The nurse measures the child's chest circumference by placing the measurement tape around their chest at the nipple line. The nurse places the child on an infant platform scale in either a sitting or supine position. The nurse measures the child's height while the child stands against the wall supported by the parent. The nurse counts the child's pulse by placing one finger on the radial artery for a full minute.

The nurse places the tape measure around the child's head at the widest part of the frontal and occipital bones. The nurse measures the child's chest circumference by placing the measurement tape around their chest at the nipple line. The nurse places the child on an infant platform scale in either a sitting or supine position. Rationale: Data collection methods should be correct for the age of the client. Data collection methods for children under the age of two are different than those for older children. A healthy 14-month-old child who is developing normally may prefer to sit on the scale than to be laid on the scale but their height should still be measured while laying down. A toddler's head and chest circumference are measured with a tape measure. The head circumference is measured at the widest point of the frontal and occipital bones, while the chest circumference is measured at the nipple line. An infant or toddler's pulse is counted apically, not radially.

A homecare nurse is caring for a 75-year-old client who has dementia. The spouse is the primary caregiver. Which of the following statements indicates that the spouse is at risk for caregiver role strain? The spouse has hired a weekly cleaning service because they "just can't keep up." The spouse states that they "have no idea how to take care of someone with dementia!" The spouse states that "our children often help with doctor's appointments." The spouse has moved the door locks to the tops of the doors because the client "goes outside if I'm not looking."

The spouse states that they "have no idea how to take care of someone with dementia!" Rationale: Many older adults help care for aging family members and have concerns about their own health and ability to continue to be a caregiver. This often makes them "secondary patients." Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Signs of role strain include verbal expressions of apprehension about providing care, concerns that support systems are inadequate, changes in their own health status, signs of ineffective coping, depersonalization, and neglect of the patient. Moving the locks is a safety strategy for dementia patients. Seeking help from family and household services are additional strategies to prevent role strain.

A parent asks the nurse about a Guthrie Bacterial Inhibitiontest that was ordered for her newborn. Which point(s) should thenurse discuss with the client prior to the test? Select all that apply. This test identifies an inherited disease Best results occur after the baby has been breastfeeding or drinking formula for two full days Routine screening of newborn infants is not mandatory in theUnited States Positive tests require dietary control for prevention of brain damage The test will be delayed if the baby's weight is less than 5 pounds (2.27 kg) The urine test can be done after six weeks of age

This test identifies an inherited disease Best results occur after the baby has been breastfeeding or drinking formula for two full days Positive tests require dietary control for prevention of brain damage The test will be delayed if the baby's weight is less than 5 pounds (2.27 kg) The urine test can be done after six weeks of age Rationale: Screening for PKU is mandated in all 50 states, though methods of screening vary. The Guthrie Bacterial Inhibition Assay (BIA) is one test used to diagnose phenylketonuria (PKU), a disease characterized by an enzyme deficiency. A blood sample is taken from the baby's heel shortly after birth, with a follow-up test 7 to10 days later. Test results are more accurate if the baby weighs more than 5 pounds and has been regularly drinking milk for more than 24 hours. A urine test is normally done after six weeks of age if a baby did not have the blood test.

The community health nurse is participating in a health policy forum. Which statement by the nurse best describes the purpose of community health research? To describe the health conditions of populations To identify the health conditions of the environment To evaluate illness in the community To explain the health conditions of families

To describe the health conditions of populations Rationale: Community health focuses on the maintenance, protection, and improvement of health especially of groups, populations, and communities. The purpose of community health research is best described as research that focuses on the health of populations in a community rather than the health of an individual. Community health nurses focus on short and long-term care for disease prevention, such as controlling the spread of communicable diseases, supporting self-management of chronic diseases, and providing education to vulnerable and underserved populations such as the homeless, elderly, and minority groups.

The nurse is assessing a client who is primigravida who is reporting contractions every 2-3 minutes. The nurse notes the presence of bloody show, intact membranes, and a cervix that is 70% effaced and 6 centimeters dilated. The nurse should understand that the client is in which phase of labor? latent active transitional accelerated

active Rationale: The first stage is the longest: it begins with the first true contraction and ends with full dilation (opening) of the cervix. Because this stage lasts so long, it is divided into three phases: latent, active, and transition. The active phase of labor is the time from the end of the latent phase of labor until the completion of cervical dilation. Cervical dilation becomes more rapid during the active phase. The cervix usually dilates from 4 to 7 cm, with 40% to 80% effacement taking place. This phase can last up to 6 hours for the nulliparous woman and 4.5 hours for the multiparous woman. The fetus descends farther in the pelvis and contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds).

The nurse is interviewing a client to determine if the client has an increased risk of skin cancer. Which of the following questions by the nurse is appropriate? "How much time do you spend in the sun each day?" "Do you use a moisturizing lotion on your skin?" "What are your current skin hygiene practices?" "Do you regularly wear cosmetics?"

"How much time do you spend in the sun each day?" Rationale: Spending excessive time in the sun increases the risk of skin cancer; therefore, the nurse should ask the client about their typical sun exposure. Moisturizing lotions and cosmetics do not increase the risk of skin cancers, and while hygiene is important for infection prevention, it does not directly affect the client's risk of cancer.

The clinic nurse is preparing a female adult client for a Papanicolaou (Pap) smear. The client states "I have never had this done before." Which statement should the nurse make? "A Pap smear can detect early cervical cell changes." "Every female client should always have a yearly Pap smear." "A Pap smear provides more information about your sexual practices." "We can confirm the presence of cancer with a Pap smear."

"A Pap smear can detect early cervical cell changes." Rationale: A Pap smear is a recommended screening tool during a pelvic exam to detect cervical cell changes. The frequency of Pap smears is determined by the pathology results. Yearly Pap smears are not indicated for all females. Information about sexual practices can be obtained through a patient interview. Further studies are needed to confirm the presence of cancer. A Pap smear is a first line screening tool.

An older adult client is prescribed a daily calcium supplement. The client asks the nurse why this is necessary. What education does the nurse provide to the client? "Consuming enough calcium will prevent injuries to your bones." "A calcium supplement is necessary to maintain bone density." "Most older adults do not consume enough calcium in their diets." "Older adults require supplementation of all vitamins and minerals."

"A calcium supplement is necessary to maintain bone density." Rationale: Osteoporosis is a disease caused by bone density loss. Calcium shifts from the bone into the bloodstream and causes bones to become weak and brittle. Older adults are at a higher risk for fractures due to osteoporosis. A calcium supplement is recommended to maintain bone density. Calcium consumption will not prevent injuries. Calcium can promote bone density but will not prevent trauma. Older adults require a calcium supplement in addition to an adequate diet. Calcium loss is greater among older adults. Supplementation of vitamins and minerals does not address the specific need for calcium.

The nurse is caring for a nullipara client who, at 12-weeks gestation, is beginning prenatal care. The client has just learned she is positive for human immunodeficiency virus (HIV). Which of the following statements by the nurse is important for the client to understand regarding infection prevention for her baby? "Breastfeeding is recommended because the health benefits outweigh the risks of HIV transmission" "Pregnancy is known to accelerate the course of your illness." "Medication for HIV will be started immediately after birth for both you and your baby." "A cesarean section will be scheduled before your membranes rupture."

"A cesarean section will be scheduled before your membranes rupture." Rationale: According to research, administration of antiviral medications during pregnancy, a cesarean birth before membranes rupture, and exclusive formula feeding have significantly reduced the incidence of perinatal transmission of HIV from mother to child. The nurse should work to encourage the mother to engage with her prenatal care and educate her about the benefits of medication for HIV during pregnancy and cesarean delivery. Pregnancy is not known to accelerate HIV.

The nurse is educating a client concerning the risk factors of osteoporosis. Which statement by the client would indicate additional education is needed? "Weight-bearing exercises may help increase my bone density." "My female gender puts me at higher risk for osteoporosis." "A few cups of coffee a day will not increase my risk of osteoporosis." "Some common medications have been linked to an increased risk of osteoporosis."

"A few cups of coffee a day will not increase my risk of osteoporosis." Rationale: Osteoporosis is caused by a combination of genetics, lifestyle, and environmental factors. Non-modifiable risk factors include advanced age, family history of osteoporosis, female gender, and a small frame. Modifiable risk factors include lifestyle and environmental factors. Lifestyle and environmental risk factors include a sedentary lifestyle and increased use of caffeine, tobacco products, and alcohol. Common medications that could cause osteoporosis are corticosteroids, aluminum-based antacids, loop diuretics, and supplemental thyroid hormones.

The nurse is educating clients at a community center about diabetes mellitus. Which of the following statements should be included in the teaching? "African-American individuals have a higher risk of diabetes." "You are low risk if you avoid adding salt to your food." "Diabetes is more likely if you are physically active." "You can lower your risk of diabetes if you move to a colder climate."

"African-American individuals have a higher risk of diabetes." Rationale: African American clients are at an increased risk of developing diabetes mellitus type 2. Lowering sodium intake is beneficial but does not indicate that the client is "low-risk." Physical activity decreases the risk of DM2, and relocating to a cooler climate does not change the risk of DM2.

A nurse is caring for a client in the first trimester of pregnancy whose rubella titer is negative. Based on this result, which of the following education should the nurse provide? "You should expect to receive a rubella booster during the 2nd trimester." "After you give birth, you will receive a booster for rubella." "During your third trimester, you should get the rubella booster." "We will need to give you a rubella booster today."

"After you give birth, you will receive a booster for rubella." Rationale: Screening for rubella occurs during the first prenatal visit to determine immunity. A rubella antibody titer of 1:8 or greater proves evidence of immunity. Women who are not immune should be vaccinated during the immediate postpartum period, so they will be immune before becoming pregnant again. Nurses need to check the rubella immune status of all new mothers and should make sure all mothers with a titer of less than 1:8 are immunized prior to discharge after the birth of the newborn. Advise pregnant women to avoid live virus vaccines (MMR and varicella) and to avoid becoming pregnant within 1 month of having received one of these vaccines because of the theoretical risk of transmission to the fetus.

The nurse is gathering a client's health history. Which of the following questions should be included to assess the client's lifestyle choices? "Do you have a family history of cardiovascular disease?" "How many times do you exercise per week?" "Does anyone in your household smoke tobacco?" "Are you able to perform all of your self-care independently?"

"How many times do you exercise per week?" Rationale: The nurse should ask the client questions about activity, substance use, diet, sexual health, alcohol use, etc. to assess the client's lifestyle choices. All other responses are questions about the client's health but are not lifestyle-based questions.

the nurse is teaching an adolescent client and the parent about implementing peritoneal dialysis (PD) at home. Which of the following information should the nurse include in the teaching? "It is a good idea to prepare a snack for your child to eat while receiving the treatment because children typically feel hungry." "Allow your child to perform a pretend procedure on a doll while receiving the treatment to prevent boredom." "Try to avoid using humor with your child while performing the treatment because your child may feel made fun of." "Allow your child to independently perform as much of the procedure as safely as possible."

"Allow your child to independently perform as much of the procedure as safely as possible." Rationale: The developmental stage of the adolescent is to achieve a sense of identity. Allowing the child to perform as much of the procedure as possible and make decisions or order supplies will help the child achieve self-identity. Children often feel full when receiving PD and will not want to eat while receiving the treatment; it is best to offer liquids. The adolescent would not be an appropriate age to offer a doll to, but rather have games, electronic devices, or peers to talk/text with during the treatment to prevent boredom. Effective communication techniques to use with the adolescent include creativity and humor, respect, appropriate medical terminology, and nonjudgment.

The nurse is teaching the parents of an infant about expected growth and development. Which of the following information should the nurse include in the teaching? "You can expect the infant to double birth weight by one year of age." "You should see your infant's first tooth start to erupt around three months of age." "Around eight months of age, your infant should be able to sit up securely without any support." "Around six months of age, your infant should start to roll from back to front and front to back."

"Around eight months of age, your infant should be able to sit up securely without any support." Rationale: Infants who develop as expected should be able to sit upright and securely without any support around eight months of age. Around four months of age, infants will turn front to back and back to front. By six months of age, infants should double their birth weight, and by one year, infants should triple their birth weight. The first tooth typically erupts around six months of age.

A client asks the nurse about including her 12-year-old son in the care of their newborn sister. Which response is an appropriate initial statement by the nurse? "Focus on your son's needs during the first few days at home." "Suggest that your partner spend more time with your son." "Ask your son what he would like to do to help with the baby." "Tell your son what he can do to help with the baby."

"Ask your son what he would like to do to help with the baby." Rationale: A 12-year-old boy is at the age where he may be interested in assisting his parents with the care of a newborn sibling, and should be encouraged to do so with supervision. This will promote bonding between all family members, and the older child will feel included with the new changes in the family.

The nurse is interviewing a client who is 11 years old. Which statement by the client would indicate the need for further developmental assessment? "I love to go on field trips and learn about new things." "At school, we read books, and my dog is brown." "I like strawberry ice cream, but my friends like chocolate." "A bowling ball is heavy, but a car is heavier."

"At school, we read books, and my dog is brown." Rationale: Between the ages of 7-12 years old, children think logically and begin to classify objects into categories. They are also aware of relationships, such as increasing/decreasing size and weight. The response, "At school, we read books, and my dog is brown" demonstrates static thinking (two unrelated thoughts within a sentence), and this likely indicates a lower cognitive level than expected. This warrants additional assessment of the client's developmental status.

The parent of a 2-year-old hospitalized child asks the nurse why the child starts screaming every time the parent gets ready to leave the hospital room. How should the nurse respond? "At this age, this is a normal response to the fear of being separated from you." "Don't worry; that behavior will stop in a few days with patience from you." "I think it would be best not to stay with the child while in the hospital." "You might want to "sneak out" of the room once the child falls asleep."

"At this age, this is a normal response to the fear of being separated from you." Rationale: The protest phase of separation anxiety is a normal response for a child this age. In toddlers ages 1 to 3, separation anxiety is at its peak. After three years of age, it begins to diminish until the adolescent years when the behavior is minimal. In addition, the stress of being hospitalized is most likely adding to the child's separation anxiety. The other responses are incorrect and nontherapeutic.

The nurse is teaching a client about preventing cardiovascular disease. Which of the following information should the nurse include in the teaching? "Avoid starting habits like smoking cigarettes." "Maintain a body mass index (BMI) of 30 to 35." "A healthy systolic blood pressure should be between 120 and 129 mm/Hg." "Resistive isometric exercises are the best type of exercise to improve circulatory function."

"Avoid starting habits like smoking cigarettes." Rationale: Smoking is a modifiable behavioral risk factor that should be taught to clients to help prevent illnesses like cardiovascular disease. Systolic blood pressure for an adult should be under 120 mm/Hg; 120 to 129 mm/Hg is considered elevated. A BMI of 25 to 30 is considered overweight, and over 30 is considered obese, which places a client at higher medical risk of coronary heart disease. Resistive isometric exercises are those in which an individual contracts the muscle while pushing against a stationary object or resisting the movement of an object. This promotes muscle strength and provides sufficient stress against bone to promote osteoblastic activity. The best exercise program is a combination of isotonic, isometric, and resistive exercises.

The nurse is preparing to discharge a client and her newborn after an uncomplicated delivery. Which of the following statements should be included in the discharge teaching? "Babies should have six or more wet diapers per day." "Put the baby to sleep with a blanket each night." "Newborn sleep-wake patterns are the same as adult sleep patterns." "Yellowing of the newborn's skin is a normal finding."

"Babies should have six or more wet diapers per day." Rationale: Urine and stool output are clear indicators of an infant's input and should be monitored to ensure that the baby is urinating at least six times per day. The sleep-wake cycles of an infant start opposite from adult sleep cycles and slowly shift to a daytime schedule. Babies should sleep alone in a crib or bassinet. Yellowing of the newborn's skin indicates high bilirubin levels and should be further assessed by the healthcare provider.

The nurse is caring for a gravida 2 para 1 client in the 10th week of her pregnancy who states, "I've never urinated as often as I have for the past three weeks." Which response would be most appropriate for the nurse to make? "Having to urinate so often can be annoying. I suggest that you watch how much fluid you are drinking and limit it." "You shouldn't be urinating this frequently now; it usually stops by the time you're eight weeks pregnant. We will check your urine for glucose." "By the time you are 12 weeks pregnant, the frequency that you need to urinate will decrease, but it is likely to return toward the end of your pregnancy." "Women do not usually experience frequent urination in the first trimester. Are you experiencing any burning sensations?"

"By the time you are 12 weeks pregnant, the frequency that you need to urinate will decrease, but it is likely to return toward the end of your pregnancy." Rationale: As the uterus grows, it presses on the urinary bladder, causing an increased frequency of urination during the first trimester. This complaint lessens during the second trimester only to reappear in the third trimester as the fetus begins to descend into the pelvis, causing pressure on the bladder.

The nurse is providing discharge teaching to a postpartum client about signs of postpartum complications. Which of the following information should be included in the education? "Come to the emergency department if you are still bleeding in one week." "Call your healthcare provider if you get a fever higher than 100.4°F." "Return to the hospital if you are experiencing urinary frequency." "Notify your healthcare provider if you begin producing more than six ounces of breast milk."

"Call your healthcare provider if you get a fever higher than 100.4°F." Rationale: Maternal body temperature above 38°C (100.4°F) indicates infection, and the client should notify the provider of this finding. Bleeding (lochia) can occur for several weeks after delivery, and urinary frequency is common in the first few days after delivery. Breast milk production varies greatly from one person to another; therefore, the amount of milk produced is not a cause for concern.

The nurse is teaching parents of a newborn about umbilical cord care. Which statement should the nurse include in the teaching? "Begin tub baths as soon as you get home to help cleanse the cord stump." "The cord stump should change from brown to yellow in a day or two." "Cover the cord stump with sterile gauze until if falls off." "Call your healthcare provider if you see any redness or drainage or notice a foul smell."

"Call your healthcare provider if you see any redness or drainage or notice a foul smell." Rationale: Frequent assessments of the umbilical cord stump are necessary to detect any bleeding or signs of infection. Any cord drainage is abnormal and is generally caused by infection. Teaching should include the following tasks. Observe for bleeding, redness, drainage, or foul odor from the cord stump and report it to your newborn's primary care provider immediately. Avoid tub baths until the cord has fallen off and the area has healed. Expose the cord stump to the air as much as possible throughout the day. Fold diapers below the level of the cord to prevent contamination of the site and to promote air-drying of the cord. Observe the cord stump, which will change color from yellow to brown to black by the 2nd or 3rd day. This is normal. In 7-10 days, it sloughs off and the umbilicus heals. Never pull the cord or attempt to loosen it; it will fall off naturally.

The nurse is gathering a health history for a client who is being seen for a well visit. The client states, "I am just so tired all the time. I don't understand it." Which question by the nurse would be appropriate to further assess the client's concern? "Do you take any medications that make you sleepy?" "Does anyone else in your household experience sleep issues?" "How many hours on average are you sleeping each night?" "Can you tell me more about the fatigue you're experiencing?

"Can you tell me more about the fatigue you're experiencing? Rationale: When interviewing a client about a concern, it is best to use open-ended questions that allow the client to provide more details about the issue. All other responses are closed or direct questions that prompt the client to give very short (often one-word) answers.

The nurse is educating a client about sexual health practices. Which of the following questions by the nurse is most appropriate to assist the client with identifying unsafe sexual practices? "Do you know how many unplanned pregnancies occur each year?" "Did you know that unprotected sex increases the risk of STIs?" "Do you always use a contraceptive when you have sex?" "How common do you think HIV is in the community?"

"Did you know that unprotected sex increases the risk of STIs?" Rationale: Asking the client about their knowledge of the risk of unprotected sex allows the nurse to identify knowledge gaps in the client's sexual education and have conversations about their own personal practices. Unplanned pregnancy and contraceptive use are important conversations to have but are not the best answer to address risky behaviors. HIV prevalence can be included in the conversation but is not the best response to this question.

The nurse is assessing a client who has recently been admitted to the acute care facility. Which of the following questions by the nurse is appropriate to assess the client's lifestyle choices? "Don't you know that cigarettes are bad for you?" "Does anyone in your family have a problem with alcohol?" "Do you currently use any illegal substances?" "Have you ever attended a substance rehabilitation program?"

"Do you currently use any illegal substances?" Rationale: The nurse should ask the client questions about activity, substance use, diet, sexual health, alcohol use, etc. to assess the client's lifestyle choices. All other responses do not address current lifestyle practices.

The nurse is assessing a female client in an outpatient clinic. Which of the following questions should the nurse ask to screen for an increased risk of breast cancer? "Do you take any hormonal birth control?" "Have you ever had breast surgery?" "How long does your menstrual cycle last?" "What geographic location are you from?"

"Do you take any hormonal birth control?" Rationale: The presence of hormones, in particular estrogen and progesterone, throughout a woman's life cycle and lifestyle choices have an influence on the risk of developing breast cancer. Breast surgery, menstrual cycle, and geographical location do not affect the likelihood of breast cancer.

A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). Which of the following questions would be an appropriate screening question? "What is your current relationship status?" "Do you use a condom when you have sexual intercourse?" "Do you currently have a sexually transmitted infection?" "How many children do you have?"

"Do you use a condom when you have sexual intercourse?" Rationale: In order to assess the risk of STI contact, the nurse needs to gather information on current sexual health practices, such as contraceptive use or the number of sexual partners. Asking the client if they currently have an STI is an important assessment question but does not evaluate risk of future STIs. The client's relationship status and number of children they have does not directly affect the risk of STIs.

The nurse is interviewing an adolescent client who states, "I am sexually active, but I don't want my parents to know." Which question by the nurse is appropriate to assess the client's health promotion practices? "Do you use condoms or birth control when you have sex?" "Are you afraid to tell your parents that you are sexually active?" "Have you had contact with any sexually transmitted infections?" "How old were you when you had sex for the first time?"

"Do you use condoms or birth control when you have sex?" Rationale: To assess the client's need for contraception, the nurse should ask a non-biased question that addresses the client's current sexual practices. Sexual history questions should be included in the assessment but do not directly affect the client's need for contraception.

The nurse is interviewing a client who has recently been diagnosed with HIV. Which of the following questions by the nurse is appropriate to assess current lifestyle choices? "Who did you get HIV from?" "Do you use injectable substances?" "How many children do you have?" "Do you identify as male or female?"

"Do you use injectable substances?" Rationale: To assess lifestyle choices, the nurse should ask questions about substance use, sexual practices, diet, activity level, etc. In this case, the client has a new diagnosis of HIV; therefore, the nurse should ask questions about sexual health, use of injectable drugs, needle sharing, or anything else that could transmit the virus to another person.

The nurse is caring for an adolescent client who is seeking care for new onset facial acne. Which question by the nurse is appropriate to evaluate the client's feelings on body image? "How long has this acne been occurring?" "Does acne affect how you feel about yourself?" "Does anything make your acne worse?" "Have you had any thoughts of harming yourself?"

"Does acne affect how you feel about yourself?" Rationale: Body image can be negatively impacted by physical changes in puberty, like acne. Asking the client how it makes them feel about themselves is an appropriate way to begin discussing body image. All of the other responses do not address the topic of body image or self-esteem.

The nurse is educating a 17-year-old client on health risks within the adolescent population. Which of the following statements should be included in the teaching? "Cut back on your salt intake to avoid anxiety." "Don't ride with anyone who has been drinking." "Your current body mass index (BMI) can predict your risk of adult cancers." "Urinating after sexual intercourse reduces the risk of sexually transmitted infections."

"Don't ride with anyone who has been drinking." Rationale: In the adolescent population, alcohol and substance use is a common practice, and it is important that clients understand not to drive while intoxicated or ride with someone who is intoxicated. Sodium does not affect anxiety. BMI can change drastically in the adolescent period; therefore, it is not a reliable indicator of future disease. Urinating after sex reduces the risk of urinary tract infections, not sexually transmitted infections.

The parent of a 4-month-old infant asks the nurse about how to protect the child from sunburn. Which of these statements is the best advice about sun protection for infants? "Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." "Liberally apply a sunscreen with the minimum sun protective factor of 15 all over the child's body." "You should keep the baby inside unless it's cloudy outside." "Sunscreen should not be used on children."

"Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." Rationale: Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned. A hat and light protective clothing should be worn. Sunscreen is not generally recommended for infants under the age of 6 months; however, the American Academy of Pediatrics states that it can be applied to small areas of the baby's skin that are exposed to the sun (such as the baby's face or the back of the hands).

The parents of a 2-year-old client state they are concerned with behavior the child is exhibiting, including temper tantrums and refusing assistance from the parents. Which response by the nurse demonstrates comprehension of the developmental level of this child? "At this age, the child will use past and present experience to determine future goals. They will reflect on their place in society." "This behavior is learned from their environment. Monitor the behavior of older siblings to prevent the behavior from worsening." "It sounds like your child may have a developmental delay. This behavior needs to be further evaluated by the health care provider." "During toddlerhood, children desire autonomy. These behaviors can be frustrating but are considered normal."

"During toddlerhood, children desire autonomy. These behaviors can be frustrating but are considered normal." Rationale: According to Erikson, the toddler will develop a sense of autonomy while overcoming a sense of doubt or failure. The toddler will most likely exhibit negativism as they explore autonomy and use terms like "no" or "me do." The characteristics of negativity, ritualism, and swift mood swings can be exhausting to parents. Parents should be supported in dealing with these normal behaviors constructively, which will help the child learn acceptable social interactions. While siblings may model this behavior, the actions described by the parents are the hallmark of toddlerhood. During adolescence, the child will begin to form their sense of identity through reflection and experiences. Toddlers do not have the capability to engage in reflective practices and are working toward autonomy, not finding their identity.

The nurse is measuring blood pressures at a community health fair. When the nurse tells a client that his blood pressure is 160/96 mm Hg, he states, "My blood pressure is usually much lower." Which of the following options would be the best response by the nurse? "Check your blood pressure again in a few months." "See your health care provider immediately." "Make an appointment to see your health care provider next year." "Get your blood pressure checked again within the next 1-2 weeks."

"Get your blood pressure checked again within the next 1-2 weeks." Rationale: High blood pressure is defined as blood pressure 130/80 mm Hg or higher. Hypertension is determined by systemic vascular resistance and cardiac output. The client's blood pressure reading is moderately high and should be rechecked. Since the client states his blood pressure is "usually much lower" the elevated blood pressure could be a concern, but it is not clear what the client considers to be a "much lower" blood pressure. Hypertension is typically diagnosed after screening. After an elevated blood pressure reading is noted on screening, the average of two or more measurements on at least two separate visits in the next couple weeks is needed to diagnose hypertension. Although the client's blood pressure is higher than normal, it is not considered a medical emergency. It is not necessary to seek medical attention immediately. The client needs to have their blood pressure reevaluated in the next couple weeks. Waiting a year, is too long.

The nurse is caring for a client who uses illegal injectable substances. Which statement by the nurse is appropriate to educate the client on reducing the risk of infection? "Getting clean needles from a needle exchange program will lower your chance of infection." "You should only inject substances into upper extremity veins to prevent infections." "Using the same injection site more than once in the same day increases the likelihood of infection." "The only way to reduce your risk of infection is to stop using injectable drugs."

"Getting clean needles from a needle exchange program will lower your chance of infection." Rationale: When injection needles are used by multiple people or kept in unclean conditions, the risk of infection increases dramatically. Utilizing a Syringe Service Program (SSP) or a Needle Exchange Program (NEP) reduces the risk of transmission of pathogens. The location of the injections and the frequency of injections do not directly affect infection rates. Cessation of injectable substance use is the ultimate goal, but it is not the only way to reduce the risk of infection.

The nurse is caring for a school-aged child who states, "My parents got a divorce." Which question by the nurse would be appropriate to assess the psychological impact of this family system change? "Why did your parents get a divorce?" "Has your parent's divorce changed the way you feel?" "How old were you when your parents got divorced?" "Who do you live with now that your parents are divorced?"

"Has your parent's divorce changed the way you feel?" Rationale: Asking a child to talk about their feelings related to a family system change, such as a divorce, is appropriate to evaluate the psychological impact the event has had on them. All the other responses do not assess the impact on the client.

The nurse is conducting a presentation on complimentary health approaches. Which statement by an attendee indicates an understanding of the teaching? "As long as an herbal preparation has been tested in the clinical setting, it is safe." "Herbal preparations are safe as long as I carefully read the label." "Herbal preparations are actually drugs; I will be careful with them." "Herbal preparations are safer to use than my prescriptions."

"Herbal preparations are actually drugs; I will be careful with them." Rationale: Herbal supplements may contain entire plants or plant parts. Many prescription drugs and over-the-counter medicines are also made from plant products, but these products are regulated by the Food and Drug Administration (FDA). The FDA considers herbal supplements foods, not drugs. Therefore, they are not subject to the same testing, manufacturing, labeling standards, and regulations as drugs. Many Americans take both dietary supplements and prescription or over-the-counter drugs. Herbal treatments may potentiate or counteract the action of prescribed medication.

The nurse is assessing a female school-aged client. The client has large breast development, is in the 95th percentile for height and weight, wears braces, and reports amenorrhea at this time. Which of the following questions should the nurse ask to assess the client's reaction to these age-related changes? "Are you happy your teeth will look perfect when your braces are removed?" "Would you like to talk about your breast development?" "Do your friends talk about having their menses yet?" "How are you feeling about your height and weight?"

"How are you feeling about your height and weight?" Rationale: The child is in the 95th percentile for height and weight, which would indicate she is taller and heavier than most females her age. The nurse should ask the child to describe her feelings about her height and weight. The other questions are closed-ended that only require a yes or no and do not facilitate communication about how the child feels.

The nurse is interviewing a client who shares that they were sexually assaulted approximately five years ago. Which question by the nurse is appropriate to assess the client's attitude about sexuality? "Would you like to be screened for sexually transmitted infections?" "Was your mental health negatively impacted by the assault?" "Can you describe the sexual assault that occurred?" "How do you feel when someone makes sexual advances towards you?"

"How do you feel when someone makes sexual advances towards you?" Rationale: To assess the client's attitude about sexuality, the nurse should ask an unbiased question that addresses the client's feelings about sex. Describing the assault is invasive and does not address the client's feelings. Asking about screening for STIs may be appropriate but does not address the client's feelings.

The nurse is assessing a client who is the primary caregiver for a family member after a recent cerebral vascular accident. Which question by the nurse is appropriate to evaluate the impact that this change has had on the family system? "How have things changed since you became responsible for your family member's care?" "Have you considered placing your family member into a skilled nursing facility?" "Has anyone provided you with a list of community resources?" "Is your family member able to complete tasks without your assistance?"

"How have things changed since you became responsible for your family member's care?" Rationale: Asking the client to talk about how the family system has changed after becoming a primary caregiver is appropriate to evaluate how the transition to being a primary caregiver has affected them. All of the other responses do not assess the impact on the client.

The nurse is speaking to the parents of a 4-year-old child who are concerned about the child wetting the bed several times a month. What should the nurse's initial response be? "You should limit fluid intake close to bedtime" "These accidents can happen at this age." "How long has this been occurring?" "Have you tried waking the child to urinate?"

"How long has this been occurring?" Rationale: Involuntary voiding or bed-wetting may occur from infections, developmental delays and anatomical malformations. Bed-wetting may also be related to hereditary factors. Following the nursing process, the initial response should be one that invites the parents to provide more details so that the nurse can gain a clearer picture of what might be happening or contributing to the child's enuresis, i.e., involuntary urination at night. Based on the additional information received, the nurse can decide how best to proceed.

The nurse is assessing a client with a history of smoking. The client participated in a smoking cessation program after receiving counseling. How will the nurse evaluate the effectiveness of the program? "How many cigarettes are you smoking daily?" "Do you feel like this program has helped you reach your goal?" "Can you tell me what sort of activities were taught in this program?" "Do you still have the urge to smoke?"

"How many cigarettes are you smoking daily?" Rationale: Follow-up care for a smoking cessation program should involve an objective evaluation. The number of cigarettes smoked daily provides a guideline for the client's progress. The client's perception of the health program and understanding of its purpose is important but does not provide an objective evaluation for smoking cessation. The client's urge to smoke may remain even after a smoking cessation program. This does not objectively evaluate whether cessation of smoking has occurred.

The nurse is collecting data from an adolescent client. Which of the following issues should the nurse address? Select all that apply. "How many sexual partners have you had in the past six months?" "How are things going at home?" "Have you gotten in any trouble lately?" "Have you decided what you are going to do after high school?" "Where are you currently living?" "Are you currently having conflicts with someone close to you?"

"How many sexual partners have you had in the past six months?" "How are things going at home?" "Where are you currently living?" "Are you currently having conflicts with someone close to you?" Rationale: Several professional organizations have published guidelines aimed at improving and maintaining health care for adolescents and young adults. The American Academy of Pediatrics, American Academy of Family Physicians, American Medical Association, and U.S. Preventive Services Task Force have similar guidelines for the health promotion of adolescents. These guidelines emphasize the need to provide health services to adolescents that meet their physical and emotional needs including physical growth and development, social and academic indicators, emotional well-being and violence, substance use, and injury prevention. Closed-ended questions about the client's plans after high school and if they have been in trouble are non-therapeutic and not appropriate in this situation.

A nurse is caring for a client who has a body mass index of 29. Which of the following questions by the nurse is appropriate to assess for the possibility of unhealthy lifestyle practices? "How long have you been overweight?" "Do you have a family history of obesity?" "Can you complete range of motion (ROM) exercises?" "How often do you take part in physical activity?"

"How often do you take part in physical activity?" Rationale: Asking a client about the frequency of their physical activity allows the nurse to gain insight into their exercise patterns. Asking questions that assess the length of time or family history may be a part of the assessment, but do not assess for the presence of unhealthy lifestyle practices. The ability to complete ROM exercises does not provide information on lifestyle.

The nurse is preparing to interview an adolescent client whose parents are also in the exam room. Which of the following nursing statements is appropriate before the interview begins? "We need to separate all of you so that I can ask questions on high-risk behaviors." "Do you mind if your parents stay in the room while I ask you some questions?" "Have you discussed sexual health with your parents prior to coming to the clinic?" "I am going to have your parents step out to complete this family health history questionnaire while we talk."

"I am going to have your parents step out to complete this family health history questionnaire while we talk." Rationale: Adolescents often take part in high-risk behaviors and may not be honest about these practices in front of their parents. Asking the parents to step out of the room and complete a separate task allows the nurse to obtain accurate subjective data from the client. Stating the need to discuss high-risk behaviors may make the parents and the adolescent uncomfortable.

The nurse is assessing a 9-year-old client who is having abdominal pain. Which of the following statements by the client would indicate that the client's cognitive ability is below the expected development? "I am hurt so bad." "My stomach started hurting yesterday." "Please don't touch my belly." "Make the pain stop soon."

"I am hurt so bad." Rationale: According to Piaget, children between the ages of 7-12 years old are in the "Concrete Operational" thinking stage. This mode of thinking is logical and systematic. They are also aware of the concept of time (past, present, future, and reversibility). Asking the examiner not to touch their belly does not indicate a cognitive delay but fear of additional pain. The response that does indicate a lower cognitive level than expected is the response "I am hurt so bad." This statement falls into the pre-operational thought process of Piaget's stages (egocentric, present tense only, and simplistic).

The nurse is discussing expected body image changes with a male adolescent client during a wellness visit. Which of the following client statements would indicate that the client is adjusting to the changes? "I am not as tall as everyone else in my class, but at least my voice is deeper to show I am maturing." "I hope I get taller than I am, because all the girls like to pat my head and tell me how cute I am." "I shave my face every morning so I can smell like a man, even though I am not growing any facial hair yet." "I feel like everyone stares at me when we are showering in the locker room, which is because I look different."

"I am not as tall as everyone else in my class, but at least my voice is deeper to show I am maturing." Rationale: The adolescent developmental stage is identity versus role confusion, and to achieve this development, it is important that the nurse assesses if the client is accepting the changed body image as it occurs. The client recognizes that he is not the tallest but is able to feel confident still about his voice being deeper. The comments about wanting to be taller, smelling like a man, and being self-conscious about body parts looking different than his peers do not indicate acceptance of his current body image.

The nurse is preparing a postpartum client for discharge with a 2-day-old baby. Which of the following statements by the client would cause the nurse concern about the client's ability to care for the infant? "I am going to switch to bottle feeding when I get home." "I am so tired that I am beginning to hallucinate." "I can't wait to be discharged, so I can have a cigarette." "I want to take a shower before I am discharged."

"I am so tired that I am beginning to hallucinate." Rationale: Any indications that the client is experiencing psychosis warrant immediate assessment. Signs and symptoms of psychosis may include auditory or visual hallucinations, disorganized behavior, flight of ideas, and psychomotor agitation. All other statements do not indicate that the client cannot care for the newborn.

The nurse is assessing a client who is 40 weeks pregnant and is reporting contractions. Which statement by the client would indicate to the nurse that the client is experiencing false labor? "I'm feeling contractions mostly in my back." "My contractions are about 6 minutes apart and regular." "I feel contractions that alternate between strong and weak." If I try to talk with my partner during a contraction, I can't."

"I feel contractions that alternate between strong and weak." Rationale: False labor is characterized by contractions that are irregular and weak, often slowing down or decreasing in intensity with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult, if not impossible, to have a conversation during a contraction.

The nurse is discussing contraceptive methods with a client. Which of the following statements by the client would contraindicate the use of a cervical cap? "My menstrual cycle is irregular." "I have sex at least 3 times per week." "I had toxic shock syndrome about 2 years ago." "My partner is allergic to latex."

"I had toxic shock syndrome about 2 years ago." Rationale: Diaphragms and cervical caps are contraindicated for clients who have a history of toxic shock syndrome. Sexual activity and irregular menstrual cycles are not contraindicated for cervical cap use. If the client or client's partner is allergic to latex, a silicone cervical cap can be used.

The nurse is assessing a client who wishes to refill a prescription for intramuscular depot medroxyprogesterone acetate (Depo-Provera). Which statement by the client indicates that refilling this prescription would be contraindicated? "I want to start a family in the next five years." "I have been taking the Depo shots for three years." "My period typically lasts six days." "My last pregnancy was four years ago."

"I have been taking the Depo shots for three years." Rationale: Long term use (more than 2 years) of Depo-Provera is contraindicated due to the medication's ability to decrease bone mineral density. The client stating that she has been taking this medication for three years indicates that they should not be prescribed this method any longer. All other responses are not contraindications.

The nurse is interviewing a client to obtain a health history. Which of the following statements by the client indicates an increased risk for cardiovascular disease? "I identify as bisexual." "My diet consists of a lot of vegetables." "My mother died of breast cancer." "I have type two diabetes."

"I have type two diabetes." Rationale: Cardiac risk factors include elevated cholesterol, hypertension, consistent hyperglycemia, diagnosed diabetes mellitus, obesity, tobacco use, sedentary lifestyle, etc. Sexual orientation and family history of unrelated cancers do not directly affect cardiovascular health. A diet that is high in carbohydrates and fat does increase cardiovascular risk, but a diet high in fruits and vegetables decreases risk.

The nurse is performing a client's weekly home health visit. Which of the following statements by the client indicates that they may be experiencing social isolation? "I haven't seen anyone since the nurse came last week." "I only have a few more days of medicine left." "I don't have any children of my own." "Everything is more difficult now that my mobility is limited."

"I haven't seen anyone since the nurse came last week." Rationale: In order to identify social isolation, the nurse should assess the client's social network, access to transportation, and desire to interact with people. In this case, the client is stating that they have not seen any other people since the last home health visit a week ago. This is cause for concern and follow-up questions should be asked by the nurse.

The school nurse is teaching a class on safe sex practices to high school students. Which statement made by a student indicates further teaching is required? "Abstinence is the best way to prevent sexually transmitted infections." "I should be careful when having anal sex so that I don't get HIV." "I should still use a condom during sex even though I am on birth control." "I should always ensure the other person consents before having sex."

"I should be careful when having anal sex so that I don't get HIV." Rationale: The human immune deficiency virus (HIV) can be transmitted via any mucous membrane. Anal sex is the riskiest type of transmission. However, unprotected sex of any kind puts clients at risk for transmission. Abstinence (not having sex) eliminates any risk of sexually transmitted infections (STIs). Birth control does not provide protection against STIs. Mutual consent is a necessary concept to discuss with adolescent clients.

A community health nurse is teaching a class on proper nutrition to a group of adolescent clients. The nurse asks a client to explain the recommended daily servings. Which statement made by the client indicates an understanding of the recommendations? "I should consume 5 ounces of grains in one day." "One small banana is equal to a serving of 1 cup of fruit." "One egg is equal to 2 ounces of protein" "It is recommended I eat 2 cups of dairy daily."

"I should consume 5 ounces of grains in one day." Rationale: MyPlate recommendations for adolescents include consuming 5 to 6 ounces of grains per day. One small banana is equal to 0.5 cups servings of fruit. One egg accounts for 1 ounce of protein. Adolescents should consume 3 cups of dairy daily.

A nurse is assessing a female client who is 13-weeks pregnant. Which statement made by the client indicates a need for prenatal counseling? "I sing to my baby every night before bed." "I should perform abstinence to ensure I don't hurt the baby." "I find myself crying at simple comments more often." "I look at my body in the mirror multiple times a day."

"I should perform abstinence to ensure I don't hurt the baby." Rationale: Sexual intercourse is safe during pregnancy unless there are complications or discomfort. The client should be informed of safe sex practices. Talking with and about the fetus is an expected response during the second trimester of pregnancy. Mood swings are an expected response throughout the pregnancy due to hormonal changes. Introversion and focusing on the changes in body image is an expected response throughout pregnancy.

A community nurse is delivering an environmental safety presentation to construction workers within the community. Which statement made by a client tells the nurse more education is needed? "I should change my clothes and shower after working with lead-based products." "I should wear gloves as my personal protective equipment (PPE) when working with lead." "A blood test can reveal the amount of lead in my system." "A well-ventilated area can prevent lead from triggering an exacerbation of my asthma."

"I should wear gloves as my personal protective equipment (PPE) when working with lead." Rationale: Lead dust particles can be inhaled and affect multiple body systems. While gloves are part of the personal protective equipment (PPE), a mask and other protective equipment are required. Changing clothes and showering after working with lead is recommended practice to reduce lead exposure. A lead blood test can reveal the amount of lead in the system. Lead dust is a pollutant and may exacerbate asthma. Good ventilation is necessary when working with lead.

The nurse is interviewing a client about self-care practices. Which of the following statements by the client indicates an understanding of unhealthy behaviors? "I smoke tobacco, but I am trying to quit." "I can't help that my family has a history of obesity." "I eat lots of red meat to make sure I get enough protein." "I drink a couple of beers each day, but I'm not an alcoholic."

"I smoke tobacco, but I am trying to quit." Rationale: The statement that the client currently smokes tobacco but is trying to quit indicates that the client recognizes that this habit is unhealthy. Drinking more than one alcoholic drink per day is considered at-risk drinking, and while red meat does have a significant protein content, it also has a high-fat content, and this meat should be consumed on a limited basis. Family history does not affect current unhealthy behaviors.

The nurse is teaching a group of clients about glaucoma. Which of the following statements made by a participant indicates an understanding of glaucoma? "I wish I didn't have to stop driving. I don't know how I'll manage." "I will take half of the usual dose of my daily antihistamine to maintain my blood pressure." "I take extra fiber and drink lots of water to avoid getting constipated." "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."

"I take extra fiber and drink lots of water to avoid getting constipated." Rationale: Any activity that involves straining increases intraocular pressure and should be avoided in clients with glaucoma. Since antihistamines can increase pressure in the eye, they should be avoided. Many people with glaucoma do give up driving at night, but most people do not have to give up driving altogether. Swimming should cause no problems (as long as the person has not had recent eye surgery), but it might be a good idea to wear goggles when in a pool.

The nurse is preparing to discharge a client home. Which statement by the client should cause the nurse to be concerned about the possibility of environmental isolation? "My dog will be so excited to see me when I finally get back home." "My children have offered to come over to help me with cooking." "I am going to need to use a walker to get around the house." "I will have to call my neighbor to help me get up the front steps of the house."

"I will have to call my neighbor to help me get up the front steps of the house." Rationale: The client stating that they will have to call a neighbor to help them get up and/or down the steps leading to the house should cause the nurse to be concerned about environmental isolation because the client is unable to independently enter/exit the home. This is cause for concern and follow-up questions should be asked by the nurse.

The nurse is teaching a client about nutrition and maintaining a healthy weight to prevent health problems. Which of the following client statements would indicate a correct understanding of the teaching? "I will begin a healthy diet if my body mass index (BMI) goes over 30." "I will maintain my body mass index (BMI) between 20 and 25." "My body mass index (BMI) should be between 15 and 20." "A healthy body mass index (BMI) is between 25 and 30."

"I will maintain my body mass index (BMI) between 20 and 25." Rationale: The client should maintain a BMI between 20 and 25 to help prevent health problems. A BMI between 25 and 30 is considered overweight and over 30 would be obese. A healthy diet should be maintained at all times but should definitely be started before a BMI of 30 is reached. A BMI under 18 is considered underweight and places the client at a higher risk of nutritional problems.

The nurse is providing teaching to the parent of a newborn during the first bottle feeding of formula. Which of the following statements by the parent indicates the need for further teaching? "I will keep the baby's head up during the feeding." "I will take several breaks to burp the baby during the feeding." "I will make sure that some air remains in the nipple at all times during the feeding." "I will expect yellow-brown stools that are pasty."

"I will make sure that some air remains in the nipple at all times during the feeding." Rationale: Keeping the baby's head in a semi-upright position helps to prevent aspiration. The nipple should be held so it fills only with formula. The infant should not be permitted to suck air as this leads to reflux. Burping will help any air that was swallowed to escape. A newborn who is bottle-fed typically has soft, formed yellow stools, and they can occur with each feeding. The frequency of stools will decline as the newborn adapts to feeding.

The home health nurse is visiting an older adult client who recently moved to this community from a much colder climate. The nurse provides the client with instructions on how to prevent a heat stroke. Which statement by the client indicates that additional teaching is needed? "I will not take my diuretic on days that I exercise." "I will increase my fluid intake if I develop cramps when exercising." "I will take my daily jog early in the morning when it is cool outside." "I will wear loose clothing and a hat when I walk my dog."

"I will not take my diuretic on days that I exercise." Rationale: It is important to exercise outside when the temperature is low as exposure to high temperature increases the likelihood of heat-induced injury. Increasing fluid intake before, during and after exercise will decrease the likelihood of muscle cramping. Loose clothing and a hat to provide shade will keep the body temperature down. While taking a medication such as a diuretic is a risk factor for non-exertional heat stroke, clients should always take medications as prescribed. If the client takes a diuretic, increasing fluid intake while exercising and being exposed to high temperatures will aid in maintaining adequate hydration status.

The nurse is taking care of a client diagnosed with major depressive disorder. The client states, "It feels so tough to perform everyday activities." Which response by the nurse helps the client achieve optimal health? "Let's discuss what everyday activities mean to you." "Let's come up with a plan to help you accomplish your everyday activities." "Tell me what your everyday activities consist of." "It is important to have someone help you with your everyday activities."

"Let's come up with a plan to help you accomplish your everyday activities." Rationale: The nurse should assess the client's ability to maintain a healthy lifestyle while promoting independence. Assisting the client with a plan is a strategy for improving mental health. Discussing what everyday activities consist of and what they mean to the client establishes a therapeutic alliance but does not promote optimal health. Telling the client they require help with everyday activities does not promote independence.

A woman comes to a clinic to discuss contraceptive options. Which statement by the client indicates to the nurse a need for additional teaching? Select all that apply. "I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection." "My diaphragm will work no matter how much weight I gain." "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential pregnancy." "Using an intrauterine device (IUD) increases my risk for a pelvic infection." "I should stop smoking before starting an oral contraceptive." "Not having any type of sexual intercourse is the only way to be sure I won't get pregnant."

"I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection." "My diaphragm will work no matter how much weight I gain." "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential pregnancy." Rationale: Women who smoke while taking oral contraceptives have an increased risk for a myocardial infarction, stroke and hypertension, so smoking cessation should be encouraged. Diaphragms should be refitted after pregnancy and pelvic surgery and whenever the client's weight changes. Medroxyprogesterone acetate (Depo-Provera) injections are effective for three months. Cervical caps, sponges and IUDs increase the risk for pelvic infections. Vaginal rings may fall out and alternative contraceptive methods should be used. Abstinence is the only method that provides complete protection from pregnancy.

A 47-year-old female client visits the clinic for an annual exam. The nurse educates the client on the types of clinical preventative services. Which statement made by the client indicates the need for further teaching? "I will follow up with a lipid panel blood test." "I need to receive my influenza vaccine every year." "I will schedule an appointment for a mammogram." "I will ensure I visit my gynecologist for a Papanicolaou (Pap) test."

"I will schedule an appointment for a mammogram." Rationale: Breast cancer screening in women is recommended every 2 years beginning at the age of 50. Middle-aged clients have a higher risk of cardiovascular disease. A lipid panel blood test measures cholesterol levels and can help determine the risk of heart disease. Influenza vaccines are recommended yearly for the prevention of respiratory illnesses. Papanicolaou (Pap) tests are recommended every 3 to 5 years for women ages 21 to 65.

The nurse is providing education to a client in her first trimester of pregnancy. Which statement indicates that the client requires additional teaching? "I will continue to take my prenatal vitamins as directed." "It is normal to have some fatigue." "I will continue to exercise as directed." "I will schedule visits with my health care provider as needed."

"I will schedule visits with my health care provider as needed." Rationale: A pregnant client should adhere to the recommended health care visit protocol throughout the pregnancy. The nurse should assist with setting up an appointment schedule for the client. Adhering to the appointment schedule with the health care provider (HCP) can help ensure a healthy pregnancy and can identify and prevent complications. Therefore, the client's statement about seeing their HCP "as needed" is incorrect and requires additional teaching. The other client statements are correct and do not require additional teaching.

The nurse working in a dermatology office is reinforcing teaching with a client about skin cancer prevention. Which statement by the client requires follow up by the nurse? "I will use a tanning bed to get a tan so I avoid the harmful rays from the sun." "I will wear a wide-brimmed hat, sunglasses and long sleeves when I'm outside." "I will avoid sun exposure between the hours of 11 am and 3 pm." "I plan to use sunless tanning creams to safely produce a tan."

"I will use a tanning bed to get a tan so I avoid the harmful rays from the sun." Rationale: The major cause of skin cancer is overexposure to the sun's harmful ultraviolet (UV) rays. Sunscreen should be worn at all times when outdoors. It is also recommended to wear a wide-brimmed hat, long sleeves and sunglasses when outside. The sun's UV rays are the strongest between 11 am and 3 pm and should be avoided if possible. Sunless tanning creams can safely produce a tan coloring of the skin without harmful exposure to the sun. The nurse should follow up on the statement about using a tanning bed because tanning beds emit the same harmful UV rays as the sun and should be avoided.

The nurse is doing preconception counseling with a woman who is planning a pregnancy. Which statement indicates that the client understands the connection between alcohol consumption and fetal alcohol disorder? "Drinking alcohol with meals helps to reduce the effects of alcohol." "I understand that a glass of wine with dinner is healthy." "Beer is not really hard alcohol, so it is safe to drink while pregnant." "If I drink, my baby may be harmed before I know I am pregnant."

"If I drink, my baby may be harmed before I know I am pregnant." Rationale: The teratogenic effects of heavy maternal alcohol consumption contribute to an increased risk of fetal alcohol spectrum disorders (FASD). The effects of FASD include brain, craniofacial, and cardiac defects. Children with FASD may also suffer from neurotoxicity and immune system dysfunction. These teratogenic effects occur even in the first weeks of pregnancy. The time between conception and the discovery of pregnancy puts the child at risk. Therefore, women considering pregnancy should not drink any alcoholic beverages. It is unknown how much, if any, alcohol is safe during pregnancy.

The nurse is educating clients in a community center about childhood obesity. Which of the following statements should be included in the teaching? "Children who are overweight often end up with eating disorders in adolescence." "Lower household income increases the risk of childhood obesity." "Protein intake should be limited to lower the risk of childhood obesity." "Children gain and lose weight much quicker than adults."

"Lower household income increases the risk of childhood obesity." Rationale: Children who come from a lower socioeconomic background often have nutritional deficits due to the high cost of healthy foods. Low-cost food is often calorie dense; therefore, obesity is more common. Protein should be increased in childhood, and the incidence of eating disorders is not directly affected by eating disorders.

The nurse is teaching a client who has a high risk for diabetes mellitus (DM), type 2, about prevention. Which of the following information should the nurse include in the teaching? "It is important for you to keep your body mass index below 30." "Including daily exercise with dietary recommendations will give you the best results when trying to lose weight." "Avoid eating foods that have more than 10 grams of sugar per serving." "The number of grams of fiber that you consume should be counted as calories when you are trying to maintain or lose weight."

"Including daily exercise with dietary recommendations will give you the best results when trying to lose weight." Rationale: Dietary recommendations combined with daily exercise is the best way to lose and or maintain body weight and decrease the risk of DM, type 2. Sugar consumption should be limited to maintain a healthy diet and prevent type 2 DM. However, the recommendation is to limit added sugar or sweeteners so that less than 10% of calories come from added sugars. The recommended daily calories can vary from person to person and can depend on the amount of exercise the person includes in their daily routine. BMI should be maintained under 24, not 30. Fiber is a polysaccharide that cannot be broken down by the digestive system, which means it does not contribute to the number of calories consumed in the diet.

The nurse is caring for a pregnant client who states, "I don't feel attractive anymore." Which statement by the nurse is most appropriate to evaluate the client's concerns about her body image? "Pregnancy doesn't make a woman unattractive." "You'll look like you did before you gave birth after you give birth." "Is there something specific that makes you feel that way?" "What does your partner think about your looks?

"Is there something specific that makes you feel that way?" Rationale: Significant body changes in pregnancy, such as weight gain or integumentary system changes, may affect the client's body image. Asking the client to provide further details about why they feel unattractive gives the nurse more information about how to address body image concerns. Asking for insight into the partner's opinion is not necessary.

A nurse is providing care to a middle-aged client during a clinic visit. The client is reading a pamphlet on hypertension and asks the nurse for more information on the disease process. Which statement made by the nurse is a tertiary prevention strategy? "High blood pressure can affect your eyesight in the future if not controlled." "Let's take your blood pressure to verify if it is under control." "Medication can help control your blood pressure." "It is important to exercise at least three times a week to control your high blood pressure."

"It is important to exercise at least three times a week to control your high blood pressure." Rationale: Physical activity recommendations to prevent complications of an illness is a tertiary prevention strategy. Educating clients on the complications of an illness is a primary prevention strategy. Taking blood pressure is a screening tool used as a secondary prevention strategy to detect an illness. Medication helps to treat a medical condition and is part of secondary prevention strategies.

The nurse is caring for a client who has refused to make any healthcare decisions without the grandparent's consent. Which statement by the nurse is most appropriate at this time? "You shouldn't need to ask permission to take a simple medication." "This procedure is necessary to save your life." "Let me know once you have come to a decision." "I am concerned that this is an abusive family relationship."

"Let me know once you have come to a decision." Rationale: Culture and religion may affect who makes health care decisions. Asking for advice from a matriarchal or patriarchal leader, such as a grandparent, is common in some cultures and should be respected by the healthcare staff. This practice alone does not indicate abuse. The nurse should avoid making statements that scrutinize the client's desire to seek family advice.

The school nurse is teaching a group of school-aged children about dental health promotion. Which statement should the nurse include in the teaching? "Let me show you how to properly brush your teeth." "I am going to check your teeth and gums for any problems." "Any issues with your teeth will be referred to an orthodontist." "Any medication you take for a tooth infection will be given at school."

"Let me show you how to properly brush your teeth." Rationale: Primary prevention strategies include assessing the knowledge base and teaching health promotion practices such as tooth-brushing. Screening for the detection of disease is a secondary prevention strategy. The initiation of referrals for further treatment is a secondary prevention strategy. Medication administration in a school setting is a tertiary prevention strategy.

The nurse is preparing a presentation focusing on the prevention of Lyme disease. Which statement by a participant would require further clarification by the nurse? "I should wear light-colored clothing and long pants when gardening." "Lyme disease can spread to my brain if I don't seek treatment." "I will call the doctor if I see a rash that looks like a bull's eye." "Lyme disease is caused by a virus similar to the flu."

"Lyme disease is caused by a virus similar to the flu." Rationale: While the symptoms of Lyme disease are similar to influenza, Lyme disease is not caused by a virus. Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is transmitted to humans by deer ticks. Because the ticks are so small, it is easier to see them on light-colored clothing. Long pants and long-sleeved shirts help protect individuals from insect bites. After being outdoors, individuals should assess their bodies for any ticks or rashes. Parents should be instructed to check children for ticks and rashes. There may be a "bull's eye" rash at the site of the tick bite. Without antibiotics, the disease can spread to the brain, heart, and joints of the body.

The parent of a 5-year-old child is concerned about an outbreak of measles in the community. The nurse understands that additional education about immunizations is needed when the parent makes which of the following statements? Select all that apply. "My child should receive a second dose of the measles vaccine now." "We should avoid playing with children with high fevers." "My child is unlikely to get measles because of their first vaccine at age one." "My child should have passive immunity from the vaccine I had as a child." "If a child develops a rash, the risk of spreading measles is gone."

"My child should have passive immunity from the vaccine I had as a child." "If a child develops a rash, the risk of spreading measles is gone." Rationale: Measles is a preventable communicable disease that was well controlled in the United States until recently. There have been outbreaks of measles in communities where children did not receive the vaccines. The Centers for Disease Control and Prevention (CDC) recommends immunization at around age one, with a booster between ages four and six. The child should be protected from the disease after the first vaccine. The period of time measles is communicable is from 3 to 5 days before the rash appears until about four days after the rash appears. In the first year of life, the child may have passive immunity from the mother. It is important to avoid being in confined spaces with any individual with a high fever.

The nurse is educating a female adolescent client about the physical changes that occur during puberty. Which statement by the client indicates an expected body image change? "My hips are much wider than they were a year ago" "Wearing a bra is so uncomfortable." "I feel like I need to hide my awkward body." "I wish all this acne would just go away."

"My hips are much wider than they were a year ago" Rationale: In puberty, the female develops breasts and wider hips. The client stating that her hips have gotten wider is expected and does not indicate any problem coping with the physical change. The other responses may be changes that occur in puberty (acne) but also indicate that the client has not adjusted to the physical change effectively.

The nurse is interviewing a client about their lifestyle practices. Which of the following statements by the client indicates that further assessment is needed? "I drink alcohol two to three times a month." "I enjoy a large cup of coffee each morning." "My weight fluctuates by a few pounds throughout the month." "My job requires me to sit for about six hours each day."

"My job requires me to sit for about six hours each day." Rationale: Working in a career that requires a large amount of time seated increases the likelihood that the client lives a sedentary lifestyle. The nurse should ask additional questions to gather more information about activity levels to determine if the client's health is at risk. Alcohol and caffeine consumption in moderation will not significantly impact the client's health. Minimal fluctuations in body weight are normal as intake and output also fluctuate. If the client had stated that the weight changes were significant, the nurse would need to further assess.

The nurse is providing education to a postpartum client. Which of the following statements should be included in the teaching? "Night sweats are common for the first few days postpartum." "Postpartum headaches are not a cause for concern." "Bedrest is recommended for the first three weeks after delivery." "Separation of the abdominal muscles is permanent."

"Night sweats are common for the first few days postpartum." Rationale: Significant diaphoresis occurs in the first three days postpartum and often increases at night. Headaches warrant the need for additional assessment as they may be a sign of postpartum preeclampsia. Bedrest is not recommended due to the increased risk of embolus formation. Diastasis recti typically resolves over time.

The nurse is educating a client about the importance of maintaining healthy lifestyle practices. Which statement by the client indicates an understanding of behaviors that may negatively impact health? "A sedentary lifestyle increases the risk of lung disease." "Increased consumption of sugary beverages increases the risk of diabetes." "Excessive sun exposure increases the risk of hypertension." "Obesity increases the risk of cardiovascular disease."

"Obesity increases the risk of cardiovascular disease." Rationale: Risk factors for cardiovascular disease include obesity, sedentary lifestyle, poor diet, smoking, etc. Drinking sugary beverages does not increase the risk for diabetes. Excessive sun exposure increases the risk for skin cancers.

The nurse is teaching a male client who is 22 years old about modifiable risk factors for disease prevention. Which of the following information should the nurse include? "Once you turn 65-years-old, you will need to have some screening tests more often." "You should ask your parents and grandparents about their health history." "You should be aware of which diseases you are more at risk for than women are." "Once you turn 25-years-old, you will have a lower risk of unintentional injuries."

"Once you turn 25-years-old, you will have a lower risk of unintentional injuries." Rationale: Modifiable risk factors that contribute to chronic illnesses include unhealthy diet, physical inactivity, tobacco use, alcohol abuse, poor control of hypertension, and elevated lipid and glucose levels. Modifiable risk factors for people who are 10 to 24 years of age include behaviors that lead to unintentional injuries. Nonmodifiable risk factors, such as age, gender, genetics, and family history, cannot be changed.

The nurse is talking on the phone with the parent of a 4-year-old child. The child was recently diagnosed with varicella. Which statement by the nurse demonstrates appropriate teaching? "Papules, vesicles and crusts will be present at the same time." "The illness is only contagious when the lesions are present." "Chewable aspirin is the preferred analgesic for pain." "I recommend using an antiviral medication to relieve itching."

"Papules, vesicles and crusts will be present at the same time." Rationale: It is appropriate to teach the parent to expect the different types of varicella (chickenpox) lesions that will be present on the child's body at the same time. Children should not be medicated with aspirin due to the possibility of developing Reye syndrome. A person with chickenpox is contagious for 1 to 2 days before skin lesions appear and remain contagious until all of the lesions have crusted over. Antiviral medications would not relieve itchy skin.

The nurse is teaching the parent of a 3-month-old infant, who has Tetralogy of Fallot, what to do if the infant experiences a hyper cyanotic spell. Which of the following information should the nurse include in the teaching? "Call for emergency response immediately." "Begin chest compressions." "Place the infant in a knee-to-chest position." "Protect the infant from injury."

"Place the infant in a knee-to-chest position." Rationale: A hypercyanotic spell occurs when a greater than usual amount of blood shunts from right to left across the ventricular septal defect, and the infant becomes more deoxygenated. The knee-to-chest position will increase systemic vascular resistance, causing increased pressure on the left side of the heart to force blood back through the pulmonic valve, thereby oxygenating more blood. Chest compressions and calling emergency response are not necessary because the infant's heart is still pumping, and the infant is still breathing. The infant may become distressed and irritable during a spell but is not in danger of injury.

An oncology nurse is reinforcing coping strategies with the family caregiver of an adult client who has cancer. What response by the client indicates additional teaching is required? "I need to take more walks to reduce my stress." "Joining one of the cancer support groups will give me a place to share my experiences." "I think we qualify for some of the community resources you mentioned." "Respite care will be a good option for us if the treatments do not work."

"Respite care will be a good option for us if the treatments do not work." Rationale: Respite care provides short-term relief for primary caregivers. It can be arranged for just an afternoon or for several days or weeks. Care can be provided at home, in a healthcare facility, or at an adult day center. It is usually not paid for by insurance, so it can be used at any time a caregiver sees the need. Respite care is designed. Providing care to seriously ill family members is commonly perceived as a chronic stressor, and caregivers often experience negative psychological, behavioral, and physiological effects on their daily lives and health. Nurses have the opportunity to intervene by providing clients with interventions to manage stress.

A nurse is teaching a group of college students about breast self-examination when a student asks for the best time to perform the monthly self-exam. What is the best reply by the nurse? "Ovulation, or mid-cycle is the best time to detect changes." "Right after the period ends, when your breasts are less tender." "The first of every month, because it is easiest to remember." "Do the exam at the same day and time every month."

"Right after the period ends, when your breasts are less tender." Rationale: The best time for a breast self-exam (BSE) is one week or seven days after the first day of a menstrual cycle. This is when the breasts are no longer swollen or tender from hormonal elevation.

The parent of an infant who is 4 weeks old asks, "When will my baby start rolling over?" Which of the following is an appropriate nursing response? "I wouldn't worry about rolling over just yet because your baby is just a month old." "Rolling from back to front as well as front to back should happen between 4-5 months old." "Rolling over is a developmental milestone that doesn't occur until 7 months of age." "I am surprised that your baby is not starting to turn from front to back already."

"Rolling from back to front as well as front to back should happen between 4-5 months old." Rationale: Gross and smooth motor development occur gradually over the first year of life. The task of rolling from back to front occurs at 4 months and by 5 months old, the infant should be able to roll from front to back as well. Expecting an infant to complete this task at 4 weeks old is not appropriate, and if the child is not able to roll over by 7 months old, this may indicate developmental delays. It is not appropriate to avoid answering the parent's question due to the baby's age.

The nurse is providing discharge teaching to a client who regularly smokes tobacco. Which of the following statements by the nurse would be appropriate to include in the education? "It takes a few years to see the benefits of quitting smoking." "Switching to vapor-based tobacco use is better for your lungs." "Smoking cessation is important to reduce your risk of cancers." "The best way to quit smoking is to stop abruptly."

"Smoking cessation is important to reduce your risk of cancers." Rationale: Smoking tobacco is a preventable risk factor for heart disease, lung disease, stroke, and cancer. Educating the client on the importance of quitting and the relation to these diseases is appropriate teaching. Preliminary benefits of smoking cessation occur within days of quitting smoking. There is no "best way" to quit; this is individualized based on the client's situation. Vapor-based tobacco products have not been proven to be better than cigarette smoking.

A nurse is caring for a postpartum client who experienced a home birth. The client asks the nurse if she can have the placenta so that she may bury it at a later time. How does the nurse respond to this request? "Who is going to help you bury the placenta?" "Why do you feel like this practice is necessary?" "The placenta needs to be disposed of properly, as it is biological waste." "Tell me more about what this practice means to you."

"Tell me more about what this practice means to you." Rationale: Nurses should be aware of cultural norms regarding placenta care. Burying the placenta is a practice that holds meaning for various cultures. Nurses should explore how this practice impacts the client. Asking who will help bury the placenta does not assess cultural meaning. "Why" questions are barriers to communication and do not promote culturally competent care. The nurse must first explore the value of the client's request.

A community health nurse is providing education for a group of assigned clients about the use of tobacco. Which statement should the nurse include in the teaching? "Smoking is more common among white-collar workers than blue-collar workers." "Second-hand smoke affects the older adult population." "Smokers use nicotine for the calming effect it produces." "The amount of smoke inhaled determines the risk of heart disease."

"The amount of smoke inhaled determines the risk of heart disease." Rationale: Cigarette smokers have an increased risk of heart disease and is proportional to the number of cigarettes smoked or smoke inhaled. Smoking is more common among blue-collar workers and those that work in construction, factories, and jobs requiring protective equipment. Second-hand smoke can affect people of any age. People with low socioeconomic status, blue-collar workers, and service staff are disproportionately affected. A common misconception is that smoking causes a calming effect. Nicotine is a stimulant. The calming effect is due to carbon monoxide found in cigarettes.

The nurse is observing a client's interactions with a newborn in the immediate postpartum period. Which of the following statements by the client indicates appropriate attachment to the new infant? "I'm nervous about changing the baby's diaper." "I need a pacifier, so the baby won't cry." "The baby looks a lot like my grandmother." "Please take the baby out of the room, so I can sleep.

"The baby looks a lot like my grandmother." Rationale: Identifying likenesses to family members is a part of something called the "claiming process" and indicates appropriate interest in the newborn. The client's nervousness about changing a diaper and asking for a pacifier may be normal but do not indicate appropriate attachment. The client asking for the baby to be removed is concerning because it may indicate poor attachment to the infant.

The nurse is providing teaching to the parents of a healthy 24-month-old client about age-related changes. Which of the following statements by the nurse is appropriate? "Your child will start wanting to sleep more during the day." "A rounded abdomen indicates that the child is eating too much." "The child should be interested in playing with toys." "Temper tantrums at this age may indicate cognitive issues."

"The child should be interested in playing with toys." Rationale: Toys that require interaction are desirable to toddlers and provide them with a sense of accomplishment when they see a change based on their action. The abdomen in the toddler stage is expected to be round due to the immaturity of the abdominal muscles. Daytime sleeping should decrease in the toddler stage. Temper tantrums are normal and occur because toddlers cannot adequately express their needs.

The nurse is teaching a 20-year-old client about sexually transmitted infections (STIs). Which statement made by the client to the nurse indicates the teaching was effective? "Gonorrhea is detected by the presence of a chancre on the genitals." "The human papilloma virus (HPV) can lead to cervical cell changes." "Untreated chlamydia can lead to secondary and late stages of the disease." "Bacterial vaginosis can cause infertility and urethral scarring."

"The human papilloma virus (HPV) can lead to cervical cell changes." Rationale: HPV is a sexually transmitted infection and one of the leading causes of cervical dysplasia. Pap smears, treatment of abnormal cells, and sexual partner examinations are important topics of discussion. A chancre is a sore associated with syphilis. Gonorrhea is characterized by a yellow discharge from the genitals. Secondary and late stages are complications of syphilis, not chlamydia. Infertility and urethral scarring can occur with an untreated chlamydia infection. Bacterial vaginosis is often asymptomatic and can occur despite sexual transmission.

The clinic nurse is preparing to administer prescribed vaccines to a 4-month-old client. The client's parent asks if the influenza vaccine will be administered during the visit. Which is an appropriate response by the nurse? "The influenza vaccine is not recommended until adulthood." "I will administer the influenza vaccine with this series of vaccines." "The influenza vaccine is recommended starting at the age of one-year-old." "The influenza vaccine can be administered in two months."

"The influenza vaccine can be administered in two months." Rationale: The Centers for Disease Control and Prevention (CDC) recommends administering the influenza vaccine starting at the age of 6 months and yearly after the initial dose.

The nurse is preparing an 8-year-old client to have a computed tomography (CT) scan of the abdomen with contrast. Which of the following statements by the nurse is appropriate to explain the procedure? "The machine doesn't hurt you if you stay still." "When you get the IV contrast, it will make you feel like you have to urinate." "The scanner is scary, but it goes very fast." "The machine takes pictures of what is inside of you."

"The machine takes pictures of what is inside of you." Rationale: Diagnostic procedures can be extremely stressful for pediatric patients. Preparing a child for the procedure by using calm communication and explaining the process at an age-appropriate level of understanding helps to reduce stress associated with the procedure.

A client who has just given birth asks the nurse what an Apgar score means. What is the best response by the nurse? "The score indicates that your newborn experienced complications during delivery." "The score is a general overview of how well your newborn is doing." "The score indicates that your newborn may have future complications." "The score is for the physician and not something you need to worry about."

"The score is a general overview of how well your newborn is doing." Rationale: The Apgar score gives the health care team a general overview of how well the newborn is acclimating and is usually done at 1 and 5 minutes after birth. It is a composite score of five assessments: heart rate, respiratory effort, muscle tone, reflex irritability and color. It is not a predictor of future problems or lack thereof. Although the score is most meaningful to the health care team, the role of the nurse is to educate and answer the client's question directly and honestly.

The nurse is caring for a 4-year-old child. The parents state they must leave the hospital but will return at 6 pm. After they leave, the child asks when he will be able to see his parents. Which option is the best response by the nurse? "They will be back right after you eat supper." "When the clock hands are on the numbers 6 and 12." "In about two hours, you will see them." "After you play awhile, they will be here."

"They will be back right after you eat supper." Rationale: Time is not completely understood by preschoolers. Preschoolers interpret time with their own frame of reference of activities that they have experienced. Thus, it is best to explain time in relation to a known and common event.

A nurse assesses the vision of a 65-year-old client. The nurse notes that the client's pupils constrict sluggishly and are 2 mm bilaterally. The client asks the nurse what the results mean. What should the nurse tell the client? "This is an expected result." "This is probably due to medications." "You will likely be referred to a specialist for further treatment." "Tell me when you noticed these changes."

"This is an expected result." Rationale: A decrease in sensory perception is an expected finding. Visual acuity diminishes, pupil size and constriction ability decrease, and peripheral vision is reduced due to structural changes of the eye. Medications can cause changes in pupillary responses. However, there is no indication that the client is taking medications. The assessment findings are consistent with aging. There is no indication of a disease process requiring further referrals. There is no indication that the client is having trouble with their vision.

The clinic nurse is collecting the health history of an 11-year old client during a wellness visit. The parent asks, "When can my child get the human papillomavirus (HPV) vaccine?" Which response would be appropriate for the nurse to make? "The HPV vaccine is recommended when your child goes through menarche." "We can administer the HPV vaccine now." "The HPV vaccine should be administered after the age of 15." "The HPV vaccine is not administered until your child is sexually active."

"We can administer the HPV vaccine now." Rationale: The Centers for Disease Control and Prevention recommend that 11-12-year-olds receive a 2-shot series of the HPV vaccine despite not being sexually active. The HPV vaccine can be administered through adulthood if not received at the age of 11-12. After the age of 15, a 3-dose series is recommended.

The nurse in a health clinic is educating a female student on ways to prevent sexually transmitted infections. Which statement indicates the client understands the nurse's teaching? "We will always use a latex condom even if we are just having oral sex." "I trust my boyfriend and we have been dating for a while now." "We don't need to use a condom because I'm taking the birth control pill." "Both of us have received the HPV vaccine and we will be immune."

"We will always use a latex condom even if we are just having oral sex." Rationale: Sexually transmitted infections (STIs) are infections spread from partner to partner during vaginal, oral, or anal sex. Prevention includes education on safe sex practices. Latex condoms provide a barrier to protect against infection and should be used during every sexual encounter including vaginal, oral, or anal sex. Birth control pills do not protect against STIs. The HPV vaccine does not protect against other STIs.

The nurse is caring for a client at a postpartum follow up visit. Which of the following questions by the nurse is appropriate to assess the client's desire for contraception? "What are your intentions for family planning?" "Have you used hormonal birth control before?" "How many uterine surgeries have you had?" "Do you participate in risky sexual behavior?"

"What are your intentions for family planning?" Rationale: To assess the client's desire for contraception, the nurse should ask a non-biased question that addresses the client's family planning intention. History questions should be included in the assessment but do not directly affect the client's need for contraception.

The nurse is caring for an older adult client who has expressed feelings of guilt about the need to move in with one of their children. Which of the following statements would be appropriate for the nurse to make? "Did you have to care for your parents when they got older?" "What concerns you most about living with your children?" "How long do you expect to live with your children?" "Are you fearful of your children?"

"What concerns you most about living with your children?" Rationale: The need for an older adult to move in with a child can create significant role strain in the parent-child relationship. The reversal of roles can make the parent feel guilty and emotional. The nurse should listen to the client and family's concerns about this transition and encourage them to express their feelings. The nurse should offer support and assist in finding solutions to their needs. The other options do not encourage the client to discuss their concerns in a supportive way.

The nurse is preparing to discharge a client from the neonatal intensive care unit who will require the use of medical equipment at home. Which of the following statements by the client's parent indicates the need for intervention? "Who do I call if I need help with the baby's equipment?" "What happens if I don't remember to feed the baby?" "Is it alright to take the baby to the grocery store with me?" "Can I take some of the monitors off to bathe the baby?"

"What happens if I don't remember to feed the baby?" Rationale: Discharging an infant with medical equipment can be very overwhelming for the parent and they have many questions about the plan of care. A question such as, "What if I forget to feed the baby?" is concerning because this is a fundamental need for the baby's survival. The other questions do not indicate that the parent is unsafe to care for the newborn.

The nurse is caring for a client who states, "I don't enjoy sex anymore." Which question by the nurse is appropriate to assess the client's perception of sexual intercourse? "How old were you when you became sexually active?" "Are you currently in a romantic relationship?" "What makes a sexual experience enjoyable to you?" "Do you have any children?"

"What makes a sexual experience enjoyable to you?" : When a client presents a sexual concern, the nurse should ask questions to gather an understanding of the client's expectations of sexuality. While questions that address relationship status, family dynamics, and sexual history may be included in the conversation, only the correct response is appropriate to assess the client's feelings.

The nurse is interviewing a client to obtain a health history. Which of the following statements by the nurse should be included in the interview? "May I listen to your breath sounds?" "What medications do you take at home?" "Which arm should I use to take your pulse?" "Can you lift your shirt to expose your abdomen?"

"What medications do you take at home?" Rationale: The components of a health history include biographic data, history of present illness, medical history, medication reconciliation, family history, subjective data review of systems, and a functional assessment of activities of daily living (ADLs). Listening to breath sounds, taking a pulse, or inspecting the abdomen are all a part of objective data collection that occurs during the physical assessment, not the health history.

The nurse is caring for a client who is being treated for a sexually transmitted infection (STI). Which of the following questions by the nurse is appropriate to assess the client's need for contraceptives? "Have you been sexually active within the last month?" "What method do you use to prevent pregnancy?" "Does your partner know that you have an STI?" "What is your sexual orientation?"

"What method do you use to prevent pregnancy?" Rationale: To assess the client's need for contraception, the nurse should ask an unbiased question that addresses the client's current sexual practices. A timeline of sexual activity and their partner's STI status should be investigated but do not directly affect the client's need for contraception.

A 4-year-old child asks his parent: "Where do babies come from?" The parent asks the nurse for guidance on how to most appropriately respond. What is the most appropriate response by the nurse? "Children ask many questions, but are not looking for answers." "This question indicates interest in sex beyond this age." "Full and detailed answers should be given to any questions." "When a child asks a question, give a simple answer."

"When a child asks a question, give a simple answer." Rationale: During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask one question, they are looking for one answer. When they are ready, they will ask for more detailed information.

The nurse is assessing a client for barriers to learning. Which of the following statements by the client should the nurse identify as a barrier? "I hope you have a video for me to watch because that would be the best way for me to learn." "I am very excited to learn today because I want to go home so I can continue living my life." "How long will it take for me to learn everything I need to know to take care of myself?" "When can we get started because I am very anxious about everything I need to know?"

"When can we get started because I am very anxious about everything I need to know?" Rationale: The nurse should recognize that pain, fatigue, depression, anxiety, or other physical or psychological symptoms can interfere with the ability to maintain attention and participate in learning. Requesting a video, expressing excitement, and willingness to care for self are all signs of motivation and readiness to learn.

During the 1-month well-baby checkup, the parents respond to questions about their newborn. Which of the parents' comments is of greatest concern to the nurse? "We notice the baby is fussy and cries a lot." "The baby does not sleep for longer than two hours at a time." "When the baby spits up, it shoots across the room." "The baby seems to want to eat every couple of hours."

"When the baby spits up, it shoots across the room." Rationale: Spit-up that shoots across the room is indicative of projectile vomiting. Projectile vomiting, chronic hunger, poor weight gain, and distended upper abdomen are the clinical manifestations of pyloric stenosis. Hypertrophic pyloric stenosis (HPS) occurs when the circumferential muscle of the pyloric sphincter becomes thickened resulting in elongation and narrowing of the pyloric canal. This produces an outlet obstruction and compensatory dilation, hypertrophy, and hyperperistalsis of the stomach. This condition usually develops in the first few weeks of life, causing nonbilious vomiting, which occurs after feeding. Projectile vomiting may develop, and the infant is fussy and hungry after vomiting. Infants with HPS have nonbilious vomiting in the early stages. Vomiting usually begins at 3 weeks of age but can start as early as 1 week and as late as 5 months. Vomiting usually occurs 30-60 minutes after feeding and becomes projectile as the obstruction progresses. Initially, the infant is hungry and irritable, but prolonged vomiting may lead to dehydration, weight loss, and failure to thrive. The other comments indicate normal behavior for a 1-month-old infant.

The nurse is teaching the parent of an infant how to monitor the infant's temperature at home. Which of the following information should the nurse include in the teaching? "When using a tympanic thermometer, pull your infant's earlobe down, and insert the tip of the thermometer into the ear canal." "When using a rectal thermometer, insert the thermometer 0.25 inches past the tip into the rectum, and hold in place for one minute." "A temporal artery thermometer should be slid back and forth across the infant's forehead with the sensor part flat against the skin for 3 minutes." "An axillary temperature can be obtained by placing the tip of the thermometer even with the infant's nipple line and under the arm."

"When using a tympanic thermometer, pull your infant's earlobe down, and insert the tip of the thermometer into the ear canal." Rationale: The correct technique is described for using the tympanic thermometer. A rectal thermometer should not be inserted any further past the tip and should be held in place for 5 minutes. The temporal artery thermometer should be slid, with the sensor part flat against the skin, across the forehead and down the hairline to where the hairline stops near the neck. An axillary temperature is obtained by placing the tip of the thermometer securely into the infant's armpit/axillary area and holding the arm in place over the top of it until the thermometer registers.

A nurse is performing a psychosocial assessment on a 23-year-old female client who is primigravida. The client states, "I am so overwhelmed thinking about having to care for this baby." What is an appropriate follow-up statement by the nurse? "You will be fine. It is normal to feel this way." "It is always overwhelming for first-time moms." "How does your partner feel about the baby?" "Who will be helping you care for the baby?"

"Who will be helping you care for the baby?" Rationale: The nurse should assess the client's support systems to ensure the client has the appropriate support during pregnancy, childbirth, and the postpartum period. Stating that the client will be fine is false reassurance. Stating that first-time mothers are all overwhelmed does not address the client's individual concern. The nurse is assuming the client has a partner and does not address the client's concern.

The nurse is caring for a client who identifies with a culture that the nurse is not familiar with. Which of the following questions by the nurse would be appropriate to ask the client about the role of family in the plan of care? "Are you able to make your own healthcare decisions?" "Is there anyone that you would like us to withhold information from?" "Can your partner be here every morning to talk to the providers?" "Who would you like included in discussions about your health?"

"Who would you like included in discussions about your health?" Rationale: When a nurse is unsure of a client's cultural preferences, they should ask unbiased questions to gain understanding. Assuming the client's partner will need to be present for healthcare discussions is not appropriate. Asking the client if they are able to make their own decisions may be offensive.

A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 mL of whole blood, the hemoglobin and hematocrit are within normal limits. The client asks the nurse whether she should continue to breastfeed the infants. Which statement by the nurse is most supported by evidence-based practice? "Yes, because breastfeeding will help to contract the uterus and reduce the risk of bleeding." "No, because breastfeeding twins will take too much energy after the hemorrhage." "No, because breastfeeding should be delayed until the "real milk" is secreted." "Yes, because the blood transfusion provides additional immunoglobulins to the infants."

"Yes, because breastfeeding will help to contract the uterus and reduce the risk of bleeding." Rationale: The most supported evidence-based practice would be for the client to breastfeed the twins to help contract the uterus and reduce the risk of uterine bleeding. Stimulation of the breasts during breastfeeding releases oxytocin, which contracts the uterus. This contraction is especially important to enhance the prevention of hemorrhage. The other statements are not correct or supported by the literature.

A school nurse is performing a vision screening on a 7-year-old child. The child tells the nurse they have trouble reading the blackboard in class. How does the nurse respond? "Your vision does not reach full capacity until the age of 8." "You may have a condition known as myopia." "It seems like you have hyperopia and may need glasses." "This will correct itself in a couple of years."

"You may have a condition known as myopia." Rationale: Myopia (nearsightedness) is an inherited condition that causes the child to have difficulty seeing distant objects. Visual capacity should be optimally functional by age 6 or 7. Hyperopia (farsightedness) is common in school-age children. Glasses are usually not needed due to the eyes adjusting their lenses. The school-age child should have a visual acuity of 20/30 or better in each eye. Children with vision less than 20/30 should be referred for further testing.

A nurse is taking care of an older adult client who will be discharged to an assisted living facility. The client asks the nurse why they are being placed into assisted living. Which is an appropriate response by the nurse? "You are being placed into an assisted living facility because you require assistance with transfers from bed to chair." "You are fully incontinent, and an assisted living facility will provide staff to assist you with toileting." "You are disoriented to time, place, and person and will benefit from being around other clients at the assisted living facility." "You often forget to bathe and perform hygiene, so the staff at the assisted living facility can help remind you."

"You often forget to bathe and perform hygiene, so the staff at the assisted living facility can help remind you." Rationale: Assisted living can provide services to older adults who have impaired functionality and require protective oversight. An older adult client who is able to provide their own hygiene but requires reminders or structure can benefit from an assisted living facility. Options A, B, and C require a nursing facility. Nursing facilities provide a living arrangement in which clients require 24-hour nursing supervision. A client who is unable to transfer from bed to chair is at high risk for falls. A client who is fully incontinent and requires assistance with toileting is at high risk for skin breakdown. A client who is disoriented to person, place, and time is at risk for falls, poor judgment, and injury.

The nurse is educating a client who is pregnant about a scheduled amniocentesis. Which statement should the nurse include in the teaching? "You will need to shower with the antiseptic scrub provided on the morning of the procedure." "You will receive a sedative by mouth when you arrive for the test." "You will be asked to use the restroom prior to the start of the test. "You will be asked to turn on your left side during the procedure."

"You will be asked to use the restroom prior to the start of the test. Rationale: Amniocentesis involves a transabdominal puncture of the amniotic sac to obtain a sample of amniotic fluid for analysis. The fluid contains fetal cells that are examined to detect chromosomal abnormalities and several hereditary metabolic defects in the fetus before birth. Before an amniocentesis, the woman should empty her bladder to reduce the risk of bladder puncture during the procedure. Showering with an antiseptic scrub and preprocedural sedation are not necessary. The woman is positioned in a way that provides an adequate pocket of amniotic fluid on ultrasound.

A 12-month-old child is receiving a hepatitis A vaccine. The child's parent verbalizes to the nurse, "I am so glad my child won't be receiving vaccines for a while." What is the nurse's response to this statement? "Bring your child in when you feel ready for their next dose." "A second dose is required within the next three months." "You will have to bring your child in within a year to receive another dose. "I agree. Children receive so many vaccines at once."

"You will have to bring your child in within a year to receive another dose. Rationale: The hepatitis A vaccine is a 2-dose vaccine administered initially at the age of 12 months. The second dose should have a minimum interval of 6 months and be completed by the age of 23 months. The nurse should be objective in educating the child's mother regarding immunizations.

A nurse is educating a female client about using basal body temperature to assist in determining when ovulation will occur. Which of the following statements will the nurse include in the teaching? "You will need to check your temperature each day before getting out of bed." "Take your temperature in the evening each day, so you will get a true basal temperature." "Take your temperature during the time that you believe you are ovulating." "Choose a time that is convenient to take your temperature at the same time each day."

"You will need to check your temperature each day before getting out of bed." Rationale: The basal body temperature (BBT) refers to the lowest temperature reached on awakening. BBT is slightly lower in the follicular phase (the first half of the menstrual cycle) and rises after ovulation and stays raised throughout the luteal phase (the second half of the menstrual cycle). This rise in temperature happens in response to progesterone, which is released after ovulation occurs. To measure basal temperature, the client must take her temperature every morning at the same exact time before getting out of bed. The client must try not to move too much, as any activity can raise the body temperature slightly.

The nurse is caring for clients in a rural heart failure clinic. Which of the following clients is experiencing a disparity in accessibility to healthcare? A 67-year-old retired client who needs a cardiac magnetic resonance imaging (MRI) to determine the cause of heart disease and has to be sent to another facility for radiology services A 70-year-old retired client who cares for his chronically ill spouse, who states, "It is difficult to come to all of these appointments when the drive to get here is over an hour" A 60-year-old client who is self-employed and being followed after a myocardial infarction and is worried about how they will pay since they "haven't been able to work" A 60-year-old client with a pacemaker, who appears modest and prefers to be seen by a healthcare provider of the same gender.

A 70-year-old retired client who cares for his chronically ill spouse, who states, "It is difficult to come to all of these appointments when the drive to get here is over an hour" Rationale: Nurses providing community-based care must know about the five "As" of access to care: affordability, availability, accessibility, accommodation, and acceptability. Affordability is the client's ability and willingness to pay for services. Availability is the extent to which the provider has the resources, such as personnel and technology, to meet the client's needs. Accessibility refers to geographic accessibility, determined by how easily the client can physically reach the provider's location. Accommodation is how the provider's operation is organized in ways that meet the preferences of the patient. Acceptability is the extent that the client is comfortable with the more immutable characteristics of the provider and vice versa. These characteristics include the age, sex, social class, and ethnicity of the healthcare provider (and of the client).

A nurse is caring for a client during a nonstress test (NST). At the end of a 40-min period of observation, the nurse notes the following findings: the fetal heart rate baseline is 135 beats per minute with minimal variability and no accelerations. There are two decelerations of 15 beats per minute in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. How should the nurse interpret these findings? Fetal tachycardia Fetal bradycardia A reactive pattern A nonreactive pattern

A nonreactive pattern Rationale: Prenatal non-stress testing (NST) is a non-invasive method used to test fetal well-being before the onset of labor. An NST functions as a part of the biophysical profile. NST can be used from 32 weeks gestation to term to detect the presence of fetal movements and assess fetal heart rate acceleration. The test is used to determine if a fetus is at risk for intrauterine death or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal hypoxemia. A normal, reactive NST indicates fetal activity as evidenced by two or more accelerations peaking at 15 bpm or more above baseline, each lasting 15 seconds or more, and all occurring within 20 minutes of beginning the test. If a test is not reactive, FHR should be monitored for at least 40 minutes to account for the fetus's sleep cycle. Most term fetuses have many of these accelerations in each 20 to 30 minute period of active sleep, and the term fetus seldom goes more than 60 minutes, and certainly not more than 100 minutes, without meeting these criteria.

The nurse is planning care for a postpartum client who identifies as Roman Catholic. The nurse notes that the client's newborn is critically ill. Which spiritual practice should the nurse expect the client to request? All family members in the room to pray together A priest to perform an infant baptism Time alone to recite the Call for Prayer A Mohel to perform circumcision of the infant

A priest to perform an infant baptism Rationale: The nurse must take into consideration the religious beliefs of the client when providing postpartum care. In the Roman Catholic religion, infant baptism is indicated, especially when the infant has a poor prognosis. Prayer is an important practice for various religions. However, it is not a key practice for the given scenario. The Call for Prayer recited to the infant is common in the Islamic religion. A Mohel is a ritual circumciser familiar with Jewish law. This practice is common in Judaism on the eighth day of birth.

During a nonstress test conducted at 37 weeks gestation, the client reports fetal movement 3 times. The nurse notes that when the expectant mother reports fetal movement, the fetal heart rate (FHR) increases 15 beats or more above the baseline. The nurse concludes that this test finding is which of the following? FHR variability FHR decelerations A nonreactive pattern A reactive pattern

A reactive pattern Rationale: Prenatal non-stress testing (NST) is a non-invasive method used to test fetal well-being before the onset of labor. An NST functions as a part of the biophysical profile. NST can be used from 32 weeks gestation to term to detect the presence of fetal movements and assess fetal heart rate acceleration. The test is used to determine if a fetus is at risk for intrauterine death or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal hypoxemia. NSTs are frequently used because of the low maternal and fetal risk. The NST involves 20 minutes of monitoring the FHR while assessing the number, amplitude, and duration of accelerations that usually correlate with fetal movement. A normal, reactive NST indicates fetal activity as evidenced by two or more accelerations peaking at 15 bpm or more above baseline, each lasting 15 seconds or more, and all occurring within 20 minutes of beginning the test. It is important to note that an abnormal stress test is not always ominous and can occur with a sleeping fetus. If a test is not reactive, FHR should be monitored for at least 40 minutes to account for the fetus's sleep cycle.

A nurse is assessing a client who is 4 hours postpartum. Which finding should the nurse report to the healthcare provider? Vaginal blood clots that are dime-size Blood pressure of 105/68 mmHg with a heart rate of 101 beats/min A saturated perineal pad every 15 minutes Urinary output of 35 ml/hr

A saturated perineal pad every 15 minutes Rationale: Postpartum complications include hemorrhage, anemia, and hypovolemic shock due to blood loss. The nurse should recognize the signs and symptoms of excessive blood loss and report them accordingly. Perineal pads that saturate every 15 mins or less are indicative of excessive blood loss and should be reported. Vaginal blood clots less than quarter-size are expected. Large blood clots should be reported to the healthcare provider. The heart rate is slightly elevated. However, the blood pressure is within normal limits. The vital signs do not indicate a complication. This urinary output is above the expected output of at least 30 ml/hr.

The nurse is speaking with the parents of a 3-year-old child who are concerned about the child holding its breath during a temper tantrum. Which action should the nurse take? Recommend that the parents give in when the child holds their breath to prevent anoxia Instruct the parents on how to reason with the child about possible harmful effects Advise the parents to monitor the child because breathing often resumes automatically Educate the parents on how to administer rescue breaths and chest compressions

Advise the parents to monitor the child because breathing often resumes automatically Rationale: Temper tantrums are common during the toddler years and represent normal developmental behaviors. Temper tantrums commonly occur when the child is ill, hungry, frustrated, or tired; some children may use temper tantrums to get parental attention, get something they want, or avoid having to do something they do not want to do. The majority of tantrums last 5 minutes or less. During a tantrum, the child may lie down on the floor, kick their feet, and scream as loud as possible. Some have learned the effectiveness of holding their breath until the parent gives in. The nurse should offer anticipatory guidance and advise the parents to not give in to the negative behavior, ensure a consistent response by all caregivers, and praise and reward positive behavior. The other actions are not appropriate or helpful for this developmental stage.

The nurse is assessing clients for risk factors for cancer. Which of the following ethnicities would have the highest risk? American Indian Hispanic Asian African American

African American Rationale: The nurse should identify that African American men have the highest risk for cancer. The risk is two times higher than Hispanic male clients. American Indian and Asian clients have a lower risk for cancer.

The nurse at a local community center is screening males who have sex with other males for risk factors for human immunodeficiency virus (HIV). Which of the following ethnicities would have the highest risk? African American White American Hispanic Asian

African American Rationale: Evidence shows that young black/African American males who have sex with other males (MSM) have the highest risk for HIV.

The nurse is screening clients for risk factors for glaucoma. Which of the following ethnicities would have the highest risk? Caucasian Hispanic African American American Indian

African American Rationale: The African American race has the highest risk for glaucoma compared to Hispanics, American Indians, and Caucasians.

A mother asks the nurse if she should be concerned about her child's tendency to stutter. Which assessment data would be the most useful in counseling the parent? Current family stressors Sibling position in family Age of the child Parental discipline strategies

Age of the child Rationale: During the preschool period, children use their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech patterns is a normal characteristic of language development. Therefore, knowing the child's age is most important in determining if any true dysfunction might be occurring with stuttering.

The parents of a child recovering from varicella would like the child to return to school as soon as possible. Which finding would support the nurse's assessment that the child is no longer contagious? Presence of vesicles Elevated temperature All lesions crusted Rhinorrhea

All lesions crusted Rationale: Chickenpox, or varicella, consists of a rash that begins with macules which then progresses to vesicles that break open and, finally, crust over. When all lesions are crusted, the child is generally considered to no longer be contagious or in a communicable stage. The other findings would indicate that the child is most likely still contagious.

A nurse is planning care for a female client who identifies with traditional Islamic culture. Which of the following individuals should be included in the decision-making process for the client's care? Client's partner only All members of the family Designated religious leader Community faith healer

All members of the family Rationale: Families who follow traditional Islamic culture value the family's opinion as a unit. When making decisions, these clients often prefer input from the family rather than deciding independently. When possible, include all family members in healthcare decisions.

The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach should the nurse use when responding to the parents' comments? Explain the cause of the child's illness. Allow parents to express their feelings without judgment. Focus on the child's needs and recovery. Acknowledge that early care would have been better.

Allow parents to express their feelings without judgment. Rationale: Parents often blame themselves for their child's illness. Feeling helpless and angry is normal and these feelings must be accepted. The nurse should not judge the parents in this situation and make them feel as though they should have brought the child in earlier. As part of the teaching, the nurse will explain the child's illness and needs, however it is not appropriate at this time.

The nurse is speaking with the parents of a 2-year-old child who was just diagnosed with cystic fibrosis. Which recommendation by the nurse is best? Restrict activities to inside the house Allow the child to continue normal activities Schedule frequent rest periods Limit exposure to other children

Allow the child to continue normal activities Rationale: Although cystic fibrosis causes severe damage to the lungs, physical activity remains important for the child's emotional development as well as disease management. A 2-year-old is developing autonomy and remaining active will support chest physical therapy. Exercise tends to mobilize mucus and help with expectoration. Therefore, the best recommendation is to allow the child to continue their normal activities. The other recommendations are not appropriate or necessary for this child.

The nurse is performing an abdominal assessment on a healthy client. Which of the following assessments should be completed first? Auscultating bowel sounds Percussing the abdominal cavity Palpating for the abdominal aortic pulse Assessing for rebound tenderness

Auscultating bowel sounds Rationale: The sequence of assessing the abdomen should be inspect, auscultate, percuss, and finally palpate. The nurse should not percuss or palpate the abdomen prior to auscultating bowel sounds, as this may increase peristalsis and create additional bowel sounds.

The nurse is preparing to perform a physical assessment of a preschool-aged child. Which of the following actions by the nurse is appropriate? Allow the child to play with certain tools before use Direct all interview questions to the child Separate the child from the parent during the assessment Perform the most invasive part of the assessment first

Allow the child to play with certain tools before use Rationale: Allowing the child to touch assessment tools, such as a stethoscope, before placing it on their chest helps to relieve the child's anxiety of the unknown. The child may be able to answer simple interview questions, but the caregiver will provide most of the subjective data. Removing the parent from the exam room may create separation anxiety, and the most invasive aspects of an assessment should be performed last to ensure that objective data collected is not skewed by pain or anxiety.

The nurse in a pediatrician's office is performing a physical assessment on a 2-year-old child. The nurse is attempting to obtain a tympanic temperature but the child is not cooperating. Which intervention would be most helpful in trying to obtain the temperature reading? Request that another nurse hold the child down. Allow the child to touch and inspect the thermometer. Document that the child was uncooperative. Offer a sucker as a reward for holding still.

Allow the child to touch and inspect the thermometer. Rationale: A toddler is in a developmental stage where they begin to express a need for independence and control over themselves and the world around them. Toddlers tend to resist cooperating and like to say "no" in order to assert their autonomy. The most helpful approach is to allow the child to touch and inspect the thermometer because it helps alleviate fears and aid in cooperation. Physically holding a child down is not appropriate. Offering candy is not recommended because food should not be used as a reward for good behavior or cooperation. An accurate temperature is important in a physical assessment and every effort should be made to obtain that data.

The nurse is obtaining a health history from a 14-year-old client. Which method is appropriate for this client? Have the mother present to verify the information Use the same type of language as with adult clients Focus the discussion on behaviors of the peer group Allow the client the opportunity to express feelings

Allow the client the opportunity to express feelings Rationale: Adolescents need to express their feelings during their health history. This should be encouraged by the nurse. Generally, adolescents will talk freely when provided with privacy and a nonthreatening environment. Discussing the peer group is important but not the priority. If the nurse uses the same language as with adult clients, the adolescent may not understand the questions.

The home health nurse is talking to the spouse of a client with Parkinson's disease. The spouse reports feeling frustrated because it takes the client over one hour to get dressed in the morning. How should the nurse respond? Hire a home aide to dress the client Allow the client the time needed to get dressed Leave the client in a night gown or pajamas Firmly encourage the client to dress more quickly

Allow the client the time needed to get dressed Rationale: Parkinson's disease (PD) is a degenerative neurological disorder resulting from nerve cells in the brain not producing enough dopamine, which regulates movement. People with PD experience tremors, muscle stiffness, slow movement, rigidity, poor balance, and coordination. With careful planning and activity modification, the client can maintain their ability to safely care for themselves. The nurse should plan for and allow enough time for the client to meet their own needs when dressing, toileting, and bathing. Pushing the client to dress more quickly, leaving the client in clothes meant for nighttime, and hiring someone to dress the client will work against supporting the client's independence and dignity.

A 23-year-old single client in the 33rd week of her first pregnancy tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? Focus on fetal development Ambivalence about pregnancy Acceptance of the pregnancy Anticipation of the birth

Anticipation of the birth Rationale: Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of an appropriate emotional response in the third trimester and a part of "nesting," according to Rubin. Ambivalence about pregnancy is an expected emotion during the first trimester. Acceptance of the pregnancy with a focus on fetal development is important in the second trimester.

The nurse is caring for a client who has active tuberculosis and a history of noncompliance. Which action by the nurse would represent appropriate care for this client? Ask the health care provider to change the regimen to fewer medications Ask a family member to supervise daily compliance Instruct the client to wear a high efficiency particulate air mask in public places Schedule weekly clinic visits for the clien

Ask a family member to supervise daily compliance Rationale: Direct-observed therapy (DOT) is a recognized method for ensuring clients' compliance with drug regimens. A program can be set up to directly observe the client taking the medication in the clinic, home, workplace, or other convenient location.

The nurse is assessing a 3-year-old client who is crying and touching the abdomen stating, "It hurts really bad." Which action by the nurse is appropriate to further assess this child's pain? Ask the child to rate pain using the Wong-Baker Faces Pain Rating Scale Tell the child to describe the quality of their pain Perform deep palpation over the location that is most sensitive Wait until the child stops crying to continue the assessment

Ask the child to rate pain using the Wong-Baker Faces Pain Rating Scale Rationale: The Wong-Baker Faces Scale is easily understood by most young children and is an accurate way to assess the severity of the child's pain. When assessing a 3-year-old client, it is important to choose words that are developmentally appropriate. This client most likely will not understand how to answer the question of "Describe the quality of your pain" but may be able to answer a question like "What does the hurt feel like?" Performing deep palpation over a painful area is not recommended. Waiting until the child is calm may take a significant amount of time. The nurse should comfort and reassure the child while asking the child simple questions to gather more information at this time.

Two hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4, the nurse notes that the fundus is boggy and displaced slightly above and to the left of the umbilicus. What should be the initial nursing action? Call the health care provider (HCP) immediately. Ask the client to empty the bladder. Monitor pulse and blood pressure. Assess lochia for color and amount.

Ask the client to empty the bladder. Rationale: A full bladder can displace the uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again. Assessing lochia is part of routine care after delivery unless there is a copious amount there should not be a change in the vital signs of the client. It is not necessary to notify the HCP at this time.

The nurse is caring for an adolescent client who has repeatedly made comments about how they are unhappy with the way the body changes in puberty. Which action is most appropriate by the nurse? Obtain a referral for a mental health counselor Provide the client with educational pamphlets Remove any object from the room that could be used for self-harm Ask the client to further explain feelings about body image

Ask the client to further explain feelings about body image Rationale: During puberty, there are significant body changes that occur, and some adolescents struggle with body image during this time. It is important to support and explain that these physical changes happen to everyone during adolescence. Ignoring or distraction techniques do not address the client's concerns. Removing objects from the client's room is only necessary if there is concern that the client will attempt self-harm. Feelings on body image alone do not warrant this action.

The nurse is caring for a client who asks the nurse to repeat themselves several times during normal conversation. Which of the following actions by the nurse would be appropriate to screen the client for hearing loss? Provide the client with a written plan of care Eliminate background noise during conversations with the client Ask the client to repeat whispered numbers or letters Inspect the client's middle ear using an otoscope

Ask the client to repeat whispered numbers or letters Rationale: If hearing loss is suspected, the nurse should perform the whispered voice test to screen the client for hearing difficulty. This test involves the examiner whispering three numbers or letters to the client and having the client repeat them. If the client has normal hearing acuity, they should be able to correctly repeat the whispered characters. While eliminating background noise and inspecting the client's middle ear may be done as a part of a hearing exam, they do not screen for hearing loss. Providing a written plan of care can be helpful but does not address the client's inability to hear.

The nurse is caring for a client with a new colostomy. Which of the following behaviors by the client indicates readiness to learn about ostomy care? Stating that they are ready to be discharged Asking questions about the supplies needed for appliance change Requesting that the client's partner complete their ostomy care Discussing the need to hire a home health nurse with their partner

Asking questions about the supplies needed for appliance change Rationale: One of the most important steps in providing successful client education is assessing the client's readiness to learn. Clients indicate they are ready to learn when they show an interest and acknowledge the need to learn the new information or skills. If a client is in denial, not interested, distraught, and/or preoccupied with other concerns, they will not be receptive to any teaching.

The nurse is caring for a neonate born 12 hours ago who is exhibiting a hyperactive Moro reflex and slight tremors. The previous nurse reported that the neonate's mother was using methadone during pregnancy. While developing a plan of care, which of the following actions is the nurse's priority? Assess for neonatal abstinence syndrome Offer fluids to prevent dehydration Administer loperamide to stop diarrhea Hold the infant at frequent intervals

Assess for neonatal abstinence syndrome Rationale: Neonatal abstinence syndrome (NAS) is a cluster of findings that occur in a newborn who was exposed to opiates while in the mother's womb. Two major types of NAS is due to addictive illegal use of opiates or opiate prescription drugs, such as methadone. Symptoms of NAS depend on the type of drug the mother used, how often the drug was used, and how much. Withdrawal symptoms could include tremors, irritability, high-pitched cry, hyperactive reflexes, and/or seizures. The priority nursing action is the assess the neonate for withdrawal symptoms and notify the health care provider immediately for further orders of treatment.

The obstetric nurse is providing care to a client during a prenatal visit. The client states that she is considering breastfeeding when the baby is born. Which action should the nurse take first? Teach the client about the benefits of breastfeeding. Assess the client's knowledge and perceptions about breastfeeding. Ask the client about her employer's breastfeeding policy. Provide information for a local breastfeeding support group.

Assess the client's knowledge and perceptions about breastfeeding. Rationale: The first step in the nursing process is assessment. Assessment is the collection of information obtained by the nurse in order to develop nursing problems and an education plan unique to the client. The first action the nurse should take is to assess the client's knowledge and perceptions about breastfeeding. Potential barriers to breastfeeding include embarrassment, misconceptions, employment and cultural norms. The other actions are used to improve breastfeeding success but are not implemented until after the first step of assessment has been completed.

The nurse is teaching a client newly diagnosed with diabetes mellitus, type 1, who requires insulin administration. Which of the following actions should the nurse take first? Assess the client's level of motivation to learn Evaluate the client's developmental level for learning Ask the client if they prefer that information is provided in writing Identify if the client would like a family member to be present

Assess the client's level of motivation to learn Rationale: Achievement of desired learning outcomes depends on a client's motivation to learn, readiness and ability to learn, and the environment where learning will take place. Motivation to learn is influenced by the client's belief in the need to know something. Without motivation, the client's style of learning, need for support, and ability to learn do not matter.

The labor and delivery nurse is caring for a client in active labor. The client has chosen natural childbirth with assistance from a doula and family members. Which action by the nurse would be most helpful for the client to achieve her goal of an unmedicated labor and birth? Closely monitor the interactions of the client with the doula Assess the effectiveness of the labor support team and offer suggestions as needed Have pain medication readily available and offer it on a regular basis Encourage the client to stay in bed in a side-lying position

Assess the effectiveness of the labor support team and offer suggestions as needed Rationale: A doula is a woman, typically without formal obstetric training, who is employed by clients to provide guidance and support during labor. The nurse's role involves clinical skills and administrative responsibilities that are not part of the doula's role. The nurse is responsible for assessing both the mother and fetus and remains an important part of the labor and birth in this scenario. The nurse's expertise allows the nurse to make helpful suggestions to the support persons and the client, such as encouraging the client to find comfortable positions, both in and out of bed. It is appropriate to let the client and her support persons know all of the pain control options, but it would be inappropriate to continually offer pain medication to someone who has chosen natural childbirth. Doulas use techniques such as imagery, massage, acupressure and patterned breathing to reduce a woman's pain.

A nurse is preparing to assist a mother with breastfeeding for the first time. Which of the following is a priority? Assist the mother with helping the newborn to latch appropriately Give the mother several illustrated pamphlets Darken the room and allow for privacy for the initial feeding Inform the client that breastfeeding is a skill for both the mother and newborn

Assist the mother with helping the newborn to latch appropriately Rationale: Immediate breastfeeding after birth is associated with physiological benefits for the newborn and mother. While educating about breastfeeding is important, it is essential to ensure the infant has latched appropriately. Darkening the room may be appropriate for subsequent feedings, but it is important for the nurse to support the mother and newborn during the initial feeding.

The nurse is participating in providing tertiary health prevention in a community that has had a recent increase in teenage pregnancy and births. Which of the following actions should the nurse take? Assist the teenagers with finding affordable childcare while the teenager is in school Assess females in the community who are sexually active with the use of birth control Provide information about abortion and adoption for the teenagers who are already pregnant Screen the teenagers who are pregnant for participation in prenatal care

Assist the teenagers with finding affordable childcare while the teenager is in school Rationale: Tertiary health prevention occurs when a defect or disability is permanent and irreversible and involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Assisting the teenagers who have already delivered and want to keep their child with finding childcare in order for them to finish school can assist with both the teenager and baby having a healthier and safer future. Assessing for the use of birth control, participating in prenatal care, and providing information about abortion and adoption would be secondary prevention. Abortion may not be an option for some clients depending on their beliefs, culture, and laws. This information would also not be helpful for the teenagers who have already given birth.

The nurse is concerned about the risk of paralytic ileus in a post-operative client. Which technique is essential for the nurse to employ when assessing the client's abdomen? Palpate any tender areas first Auscultate for bruits over abdominal arteries after palpation Auscultate before palpating the abdomen Start auscultating at the right lower quadrant of the abdomen

Auscultate before palpating the abdomen Rationale: The order of assessment of the abdomen is different from other body systems. Inspection is followed by auscultation for bowel sounds before percussion and palpation. Failure to adhere to this order may result in the alteration of bowel sounds from either percussion or palpation. Auscultate all four quadrants for vascular sounds after bowel sounds are assessed. It is recommended to start at the point of the ileocecal valve, slightly right and below the umbilicus, and proceed clockwise. Listen in each quadrant for a full minute. If no sounds are audible, listen for up to 5 minutes. Tender areas should be palpated and percussed last.

A nurse is preparing to perform a physical examination on an 8-month-old child who is sitting happily on the mother's lap. Which assessment should the nurse perform first? Measure the height and weight Auscultate the heart and lungs Elicit the deep tendon reflexes Examine the mouth and ears

Auscultate the heart and lungs Rationale: The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order.

The parent of a 2-year-old child reports to the nurse feelings of frustration and anger due to the child constantly saying "no" and refusing to follow directions. The nurse should explain that the child's behavior is an attempt to meet which developmental goal? Self-esteem Autonomy Initiative Trust

Autonomy Rationale: Developing a sense of autonomy is the goal of development during toddlerhood, according to Erikson. Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As toddlers attempt to express their will, they often act with negativism, or giving a negative response to requests. The words "no" or "me do" can be the sole vocabulary. Emotions become strongly expressed, usually in rapid mood swings. Understanding and coping with these swift changes are often difficult for parents. Many parents find the negativism exasperating and, instead of dealing constructively with it, give in to it, which further threatens the child's search for acceptable methods of interacting with others.

The nurse is admitting a school-age child to the pediatric unit. Which of the following concerns, provided by the child's parents, would the nurse recognize as a finding of type 1 diabetes? Decreased appetite Dry skin Weight gain Bed-wetting

Bed-wetting Rationale: Type 1 diabetes is a condition in which glucose in the blood becomes high due to a lack of insulin. In school-age children, clinical signs of type 1 diabetes include fatigue, poluria (frequent urination), polydipsia (increased thirst), polyphagia (extreme hunger), and weight loss. Diabetics usually have dryer skin. However, dry skin is not a specific finding in this child. Clients with type 1 diabetes, whose glucose is extremely elevated, will present with polyphagia and not a decreased appetite. Due to the insulin deficiency, cells are unable to use glucose for energy production. Clients with type 1 diabetes typically present with weight loss, not weight gain. Due to the insulin deficiency, cells are unable to receive glucose for energy production. As a result, cells are starving, and fats get converted to energy. Bed-wetting in a school-age child who previously did not wet the bed at night, would prompt the parents to seek medical attention. Bed-wetting could be an indication of polyuria due to excess sugar building up in the child's bloodstream, as this pulls fluid from the tissues into the blood stream.

The nurse is providing prenatal education to a client who has just found out she is 8 weeks pregnant. The woman asks how the health care provider (HCP) knew that she was pregnant by just looking inside her vagina. Which response is the best explanation for this? Pronounced softening of the cervix Plug of very thick mucus Slight rotation of the uterus to the right Bluish coloration of the cervix and vaginal walls

Bluish coloration of the cervix and vaginal walls Rationale: Chadwick's signs are a bluish-purple coloration of the cervix and vaginal walls. It develops at 6 to 8 weeks of gestation and is caused by an increased blood supply to the area. Other early signs of pregnancy include Hegar's signs (a softening of the cervical isthmus) and Goodwell's sign (a softening of the cervix). While these are early signs of pregnancy, the HCP would need to compress and palpate the tissue to assess these findings. The HCP would not see the mucus plug. The mucus plug dislodges and passes out of the body just prior to labor.

The nurse is organizing play for a small group of hospitalized children. Which playroom activity is appropriate for a group of 7-year-old children? Finger paints and water play Board games with rules "Dress-up" clothes and props Chess and television programs

Board games with rules Rationale: The purpose of play for the 7-year-old is the development of cooperation through team play or joining groups such as the Boy Scouts or Girl Scouts. Rules are a focus in this age group. Logical reasoning and social skills are developed through play. Finger paints and water play are appropriate for 3-year-old children. Dress up clothes and props are appropriate for 4 and 5-year-old children. While playing chess may be appropriate for 7-year-old children, Chess is played with just 2 players and not a group. Television programs are not appropriate for this type of activity.

The nurse is interviewing a client to verify pregnancy. What information from the client will provide presumptive findings? Select all that apply. Uterine changes Cervical changes Breast sensitivity Amenorrhea Nausea Fatigue

Breast sensitivity Amenorrhea Nausea Fatigue Rationale: A newly-pregnant client will typically report subjective (presumptive) changes such as breast sensitivity, missed period, nausea and fatigue. Uterine and/or cervical changes cannot be subjectively reported by the client but will be findings assessed during a physical exam by the health care provider

The nurse is taking care of a client with hemiplegia due to a stroke. Which activity of daily living will the nurse encourage the client to perform? Brush their teeth Transfer from a bed to a chair Ambulate independently Tie their shoes

Brush their teeth Rationale: The nurse should encourage independence as much as possible. The client should be able to brush their teeth with the unaffected side. Transferring from a bed to a chair may require assistive devices due to the client's paralysis of one side of the body. Ambulating independently is not a safe activity due to hemiplegia. The client may not be able to tie their own shoes due to the paralysis of one side.

The nurse is planning care for a client who is prescribed oral contraceptives. Which of the following outcomes should be included in the client's plan of care? Client consistently takes the pill every day. Client will experience a decrease in sexual desire. Client will discontinue barrier methods of contraception. Client denies contact with sexually transmitted infections.

Client consistently takes the pill every day. Rationale: Expected outcomes for contraception not only include the method's effectiveness but also correct use of the method and satisfaction with the method. In this case, taking the oral contraceptive daily is an expected outcome. A decrease in sexual desire is an undesirable side effect and should not be listed as an expected outcome. If the client participates in sexual interactions with multiple partners, they should continue to use barrier methods to prevent STI transmission.

The nurse is reviewing the written orders for a newly admitted client. The nurse has difficulty reading the health care provider's handwriting. Which action should the nurse take first? Leave the order for the oncoming staff to follow up on Ask the pharmacy for assistance in the interpretation Contact the charge nurse for an interpretation Call the provider for clarification of the order

Call the provider for clarification of the order Rationale: The nurse should call the health care provider to clarify this order. Relying on another person's interpretation of the order is risky. It is not appropriate to leave the order for the oncoming shift to follow up. Order entry systems are minimizing these types of problems.

The nurse is caring for a client who is in active labor who has ruptured amniotic membranes. Which action by the nurse is the priority? Start oxygen by face mask Prepare the woman for immediate delivery Check the fetal heart rate (FHR) Place the woman in the knee-chest position

Check the fetal heart rate (FHR) Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. Oxygen and positioning are the interventions for cord compression and prolapse. Delivery may not be imminent depending on cervical dilation and effacement.

The nurse is teaching a 9-year-old child to self-administer bronchodilators for asthma management. Which cognitive developmental milestone should the nurse consider for a child of this age? Children of this age apply concepts from one context to another. Abstract logic is useful for teaching concepts to children this age. Children of this age can think logically in the organization of facts. Children of this age are egocentric and highly imaginative.

Children of this age can think logically in the organization of facts. Rationale: Children in the concrete operational stage (7 to 11 years old), according to Piaget, are capable of mature thought when they are allowed to mentally or physically organize objects. Children of this age attach concepts to concrete situations. The conceptual abilities become increasingly flexible, and the child can articulate the process and perform the actions mentally. However, due to the psychomotor domain of self-administration, the child should be encouraged to demonstrate self-administration of bronchodilators. Children of the formal operational age (11 years or older) can transfer concepts learned from one context to another and may apply abstract logic. Children in the pre-operational stage (2 to 6 years old) are egocentric and highly imaginative.

The nurse is assessing a client who is 4 months old. Which of the following physical assessment findings is expected? Presence of two to four teeth in the mouth Client weight is eight pounds above birth weight Ability to sit up unassisted for thirty seconds Head circumference is less than chest circumference

Client weight is eight pounds above birth weight Rationale: From birth to 6-months-old, the infant should gain about two pounds per month; therefore, at 4 months old, a weight that is 8 pounds more than the birth weight is expected. Teeth generally erupt around 6-8 months old, and the ability to sit up unassisted occurs at 8 months of age. Head circumference is expected to be larger than chest circumference until 6 months old.

The nurse is reviewing the previous assessment findings for a newborn. The nurse notes that the first APGAR score was 8 and the next score was 9. Which category of the APGAR test is most likely the reason for the improved score? Heart rate Cry Muscle tone Color

Color Rationale: The APGAR test is an assessment used to evaluate and monitor a newborn's physical condition at 1 minute and 5 minutes after birth. The APGAR test evaluates five categories including A- appearance (skin color), P- pulse (heart rate), G- grimace (reflex irritability), A- activity (muscle tone), and R- respiratory (respiratory effort). These categories are rated on a 0 to 2 scale. A score of 0 indicates an absent or poor response and 2 indicates a normal response. A normal APGAR score ranges from 8 to 10 and no medical intervention is needed other than supporting respiratory effort and thermoregulation. It is common for the newborn to experience acrocyanosis. This occurs when the body is pink and the extremities are blue and would be scored a 1. This is the most common APGAR score deduction.

The nurse is beginning nutritional counseling with a pregnant client. Which step should the nurse take first? Question her understanding and use of the food pyramid Teach her the risks of pica during pregnancy Explain diet changes that are necessary for pregnant women Conduct a diet history to determine her normal eating routines

Conduct a diet history to determine her normal eating routines Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information. The results of this information provide the basis of the planned educational needs.

A 24-year-old female calls the health clinic and informs the nurse that she has missed two periods while using a 21-day hormone-containing contraceptive. She states that she may have forgotten to take a pill for a few days in one cycle. What is the most appropriate response by the nurse? Take the over-the-counter emergency contraceptive levonorgestrel (Plan B) Continue taking the pills, take a home pregnancy test, and call the health care provider for advice about the test results Immediately stop taking the birth control pills, and make an appointment to rule out a pregnancy Come to the clinic, and discuss different options for contraception that do not require taking a daily pill

Continue taking the pills, take a home pregnancy test, and call the health care provider for advice about the test results Rationale: It's not unusual for women who are taking hormone pills for birth control to have light periods or no bleeding at all. If a woman skips two periods in a row, regardless if she missed any pills, she should take a home pregnancy test and call the health care provider (HCP) for advice about the test results. She should not stop taking the pills and risk a pregnancy unless instructed to do so by the HCP. Plan B is a type of emergency contraception, also known as the "morning-after pill," and should be used within 72 hours after unprotected sex; it will not stop the development of a fetus once someone is already pregnant. Switching to a different form of contraception is a possibility but only after the woman confirms she is not pregnant.

The nurse reviews an order to administer Rho(D) immune globulin to an Rh-negative woman after the birth of her Rh-positive newborn. Which assessment is a priority before the nurse gives the injection? Gravida and parity Previous RhoGAM history Newborn's blood type Coombs test results

Coombs test results Rationale: Rho(D) immune globulin is given only if antibody formation has not occurred. A negative Coombs test confirms antibodies have not been formed in the mother. If the Coombs test is positive, the medication is of no value. Rho(D) immune globulin is recommended for Rh-negative mothers between 28 and 32 weeks of gestation and within 72 hours after birth. Rh-negative mothers should receive Rho(D) immune globulin at any time when there is a risk of blood mixing, including a miscarriage, an abortion, an ectopic pregnancy, or an amniocentesis. This medication provides temporary (approximately 12 weeks) passive immunity and will need to be repeated during subsequent pregnancies. It is important to note that Rho(D) immune globulin is considered a blood product. Clients should provide consent and be educated about the effects of this medication. The administration of blood products is not accepted by some cultures and religions. The nurse should accept the client's decision regarding this medication.

The nurse is assessing a client's pulse who has an irregular heart rate. Which of the following actions by the nurse demonstrates correct technique? Counting the client's radial pulse for 60 seconds Counting the client's carotid pulse for 30 seconds and multiplying by two Counting the client's apical pulse for 45 seconds Counting the client's brachial pulse for 10 seconds and multiplying by six

Counting the client's radial pulse for 60 seconds Rationale: If the client's heart rate has a regular rhythm, the nurse can count the pulse for 30 seconds and multiply; however, in this case, the client has an irregular heart rate. This means that the nurse should count the client's pulse for a full minute to obtain an accurate pulse rate.

The school nurse is counseling a sexually active teenage girl about pregnancy prevention. The teenager reports a regular 32-day menstrual cycle. The nurse informs her she is most likely to get pregnant during which days in her menstrual cycle? Days 7-10 Days 11-13 Days 17-19 Days 14-16

Days 17-19 Rationale: Ovulation occurs 14 days before the onset of menses, thus the teenager with a 32-day cycle is most likely to get pregnant between days 17 and 19. The follicular phase occurs from menstruation to ovulation.

The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. The client reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What should the nurse calculate as the estimated date of delivery (EDD)? April 8 January 15 February 11 December 23

December 23 Rationale: Naegele's rule states: Add seven days and subtract three months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

The home health nurse is evaluating the plan of care for a 15-year-old male client with muscular dystrophy. The client is mostly immobile and unable to care for himself. The client is at risk for depression due to which issue? Lack of trust Loss of control Insecurity Dependence

Dependence Rationale: A 15-year-old adolescent would be in the stage of development identity vs. role confusion (Erikson). Since this adolescent is dependent on others, it will be difficult for him to find his own identity. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal.

The nurse is providing care to a 5-year-old client who has bacterial pneumonia and requires intravenous medication. Which of the following actions should the nurse take? Explain what the intravenous medication is and what it is for to both the client and parent(s) at the same time Describe any sensations the client may experience and use a doll or stuffed animal to demonstrate how the equipment will be connected Ask another nurse or unlicensed assistive personnel (UAP) to assist with restraining the client when starting the medication to prevent any injury Allow the client to push the buttons on the infusion pump to start the infusion

Describe any sensations the client may experience and use a doll or stuffed animal to demonstrate how the equipment will be connected Question Explanation Rationale: Preschool-aged children should be given short explanations of what to expect close to the time of the procedure to reduce the amount of time the child has to worry. Using a doll or stuffed animal in a play session to demonstrate and introduce what will happen with new equipment allows the child to see that the doll is not injured during the procedure. This also allows the child to handle the equipment. The parents should receive an explanation away from the child in appropriate language for their developmental level and would also need to consent to the procedure prior to explaining it to the child. There is no need to restrain the child without assessing if the child would be cooperative with the procedure first. Restraining is the last resort and should only be used if the parent is comfortable with intervention. Allowing the child to play with equipment at this age would be appropriate but not when the equipment is actually in use. The nurse should allow the client to touch equipment attached to a doll or stuffed animal and not the client themselves because it could cause injury.

The home health nurse is assessing the ability of a client who has chronic obstructive pulmonary disease (COPD) to manage prescribed medications. The nurse notes that the client often skips months refilling the prescriptions. Which action should the nurse take? Determine if the client has difficulty paying for the medications Identify accessible public transportation to the client's pharmacy Request prescriptions for generic medications from the provider Use the manufacturers' websites to obtain coupons for one free 30-day supply for each medication

Determine if the client has difficulty paying for the medications Rationale: Cost-related medication nonadherence is a major barrier to chronic disease management. Nonadherence may include skipped or reduced doses and delaying to fill and/or not filling prescriptions. Older adults may forgo medications because of inadequate prescription coverage by insurance programs and high out-of-pocket costs. Patient pharmaceutical assistance programs provide eligible applicants with their medications at a reduced cost. Medications for more severe forms of COPD are not available in generic versions, so this is not an appropriate solution. There is no indication that the client has a barrier to accessing care, only affording care. A 30-day coupon does not address the long-term goal of medication adherence.

The nurse is assessing a client who is 4 hours postpartum from a normal spontaneous vaginal delivery with a midline episiotomy. The nurse notes the fundus is firm and midline and at the level of the umbilicus, perineal sutures are well approximated with slight edema, and moderate lochia is present. Which action should the nurse take? Assist the client to void Prepare to type and crossmatch the client Gently massage client's fundus Document the findings

Document the findings Rationale: Assessments during the fourth stage center on frequent monitoring of the woman's vital signs, the status of the uterine fundus and perineal area, comfort level, lochia amount, and bladder status. Assess fundal height, position, and firmness. The fundus needs to remain firm to prevent excessive postpartum bleeding. The fundus should be firm (feel like the size and consistency of a grapefruit) and be located in the midline. If it is not firm (boggy), gently massage it until it is firm. Once firmness is obtained, stop massaging. This client has expected assessment findings for the postpartum stage and, therefore, requires no intervention other than documentation.

The nurse is performing a routine assessment on a six-month-old infant. The child's mother states that the child weighed 7 pounds 8 ounces at birth. Which would be an appropriate finding for the weight of the child at this visit? Triple the birth weight Double the birth weight Add two pounds each month Gain six ounces each week

Double the birth weight Rationale: Appropriate growth and development of a child is an indicator of adequate nutrition, good health, and absence of chronic illness. Although growth rates vary, infants normally double their birth weight by six months. At 12 months, the weight should be triple the birth weight. Important anthropometric measurements for the pediatric population include height or length, weight, body mass index (BMI), and head circumference. The head circumference will generally be measured at every routine health care provider visit until the child is 2-years-old. The measurements will be recorded on a graph and compared to previous measurements and to percentiles of their peers. Children falling between the 5th and 95th percentile are considered to have a normal growth range

The nurse is assisting with the delivery of a newborn infant. Which intervention immediately after delivery is the priority? Dry off infant with a warm blanket Assign one minute APGAR score Obtain vital signs Apply identification bracelets

Dry off infant with a warm blanket Rationale: The priority intervention during the newborn period includes maintaining the infant's temperature by drying and warming the infant; and removing any wet blankets or towels from the infant to avoid dropping their body temperature. Maintaining the temperature of the newborn is essential to decreasing the risk of respiratory distress. Normal temperature promotes normal oxygen requirements. The cold-stressed infant may present with signs of respiratory distress and cardiac depression. Identification bands should be placed on the infant after birth, but this intervention wouldn't take higher priority than warming the newborn. The APGAR score is an important part of the initial assessment and is performed at 1 and 5 minutes after birth. This assesses the infant's overall condition at birth. The score occurs after the baby is being warmed. Vital signs are performed along with the APGAR score.

The nurse is planning primary health prevention for a community that has had a recent increase in sexually transmitted infections (STIs). Which of the following interventions should the nurse include in the plan of care? Provide information for those who are infected about available treatments Educate the community about the importance of having the sexual partner treated for the infection as well Screen the community about the use of condoms during sexual intercourse Educate the community about how the infections are transmitted from person to person

Educate the community about how the infections are transmitted from person to person Rationale: Primary prevention includes preventing STIs in the community. This can be accomplished through education about how infections are transmitted and could include the importance of using condoms to prevent transmission. Screening the community about condom use would only gather information but would not help prevent the spread of infections. Providing treatment information and education about the importance of treating both persons would be considered a secondary health intervention to prevent the spread of the infection.

The nurse is caring for the neonate immediately following vaginal delivery. Which interventions will promote temperature regulation in the neonate? Select all that apply. Bathe the newborn to remove contaminants from the delivery Encourage skin-to-skin contact with the mother Place the newborn under a radiant warmer Dry the newborn off with warm towels Wrap the newborn in blankets and use warmed caps on the newborn

Encourage skin-to-skin contact with the mother Place the newborn under a radiant warmer Dry the newborn off with warm towels Wrap the newborn in blankets and use warmed caps on the newborn Rationale: The ability to thermoregulate is not adequately developed in newborns. The nurse plays a vital role in temperature regulation, and nurses should understand that newborns, especially preterm newborns, are exceptionally vulnerable to both overheating and underheating. Newborns lose heat easily after birth. The initial method for promoting temperature regulation in stable newborns is skin-to-skin contact with the mother. The nurse should ensure that the infant transporter (isolette) is fully charged and heated. Additionally, prewarmed blankets and hats should be prepared in anticipation of delivery. The nurse should also avoid placing a temperature probe over bony prominences or areas of brown fat to ensure accurate temperature measurement. Bathing should be deferred until the newborn is medically stable and should be completed using a radiant heating source.

The nurse on a pediatric oncology unit is developing a plan of care for an 8-year-old child admitted for chemotherapy. Which intervention should the nurse include to meet the child's developmental needs, according to Erikson's theory? Provide frequent reassurance and hugs to build trust Encourage the child to engage in activities while in the playroom Talk with the child about any concerns with their body image Request for the child's parents to stay overnight

Encourage the child to engage in activities while in the playroom Rationale: According to Erikson, school-age children are in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage this group of children to carry out tasks and activities in their rooms or while in the playroom. The other interventions are more appropriate for different developmental stages.

The nurse works in a pediatric hospital. Which of the following actions should be planned in the care of an 18-month-old child? Engage the child in games with other children Hold and cuddle the child frequently Encourage the child to feed self with finger foods Allow the child to walk independently on the unit

Encourage the child to feed self with finger foods Rationale: According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. It is not until a child reaches the preschool years that they would interact and play with other children. The nurse should encourage independent activities of daily living that allow toddlers to assert their budding sense of control. Toddlers are gaining a sense of autonomy. The nurse would encourage toddlers to feed themselves. Although an 18-month toddler would still need to be held and cuddled; they would not need to be held as frequently as an infant. Although an 18-month toddler would be walking, they should not be walking independently on the nursing unit. It would not be safe.

A nurse is providing care to a breastfeeding client who is 3 days postpartum. The newborn had a birth weight of 7 lbs 6 oz and now weighs 7 lbs 1 oz. The mother expresses concern about the amount of weight the newborn has lost since birth. What intervention should the nurse implement first to minimize further weight loss? Monitor the number of wet diapers to assess for dehydration Encourage the client to offer feedings more frequently Offer formula supplements between breast feedings Continue to monitor the weight, as this is an expected finding

Encourage the client to offer feedings more frequently Rationale: Newborns usually lose up to 6% of their birth weight within the first few days of life but regain it in approximately 10 days. Encouraging more frequent feedings will promote milk production. Supplementation with formula may occur when a newborn has lost >10% of birth weight. Monitoring wet diapers is important to assess for dehydration but not to minimize weight loss.

The nurse is assessing an adolescent client who delivered a baby three weeks ago. The client tells the nurse that she is worried about not returning to her pre-pregnancy weight. Which initial action should the nurse take? Give the client several pamphlets about healthy postpartum nutrition Review the client's weight pattern during the past year Ask the client to record her dietary intake for the next few weeks Encourage the client to talk about her concerns and self-image

Encourage the client to talk about her concerns and self-image Rationale: Body image is significant to an adolescent. The nurse must acknowledge this and initially collect more information about the client's self-image before discussing nutritional needs, diet, or exercise. Adolescents often need more support and information about what to expect after the birth of a child, especially since the postpartum period can be overwhelming. Nonjudgmental and developmentally appropriate interactions are needed to care for the physical and emotional needs of adolescent mothers.

A postpartum mother is unwilling to allow the father to participate in the newborn's care even though he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should include which focus? Talk with the father and help him accept the wife's decision Arrange for the parents to attend infant care classes Encourage the mother to express her feelings and concerns Discuss sharing parenting responsibilities with the mother

Encourage the mother to express her feelings and concerns Rationale: Encouraging the mother to express her feelings may lead to the resolution of competitive feelings in a new family. Cultural influences may also be clarified at this time.

The nurse is planning to care for a preschool-aged child with a recent illness. Which nursing intervention would be most appropriate for the nurse to implement based on the child's developmental needs? Allow the child to make realistic goals Encourage the opportunity to make choices Allow the child to explore the playroom Encourage the use of imaginary play

Encourage the opportunity to make choices Rationale: A preschool-aged child's age ranges from 3 years to 5 years. During these years, Erikson's stage of development puts them in the initiative versus guilt stage. Within this stage, the nurse should allow the child an opportunity to make their own choices and act upon those choices. This will allow the child to have increased initiative and learn to make decisions for themselves. If they make the wrong decision they will feel guilty and will need further guidance. Allowing the child to make realistic goals does not occur until ages 6 to 11 while in the industry versus inferiority stage. Imaginary play and having the child explore the playroom is at a much younger stage, autonomy versus self-doubt, and the child should have resolved that stage.

The nurse is teaching a community class about human immunodeficiency virus (HIV) prevention. Which behavior increases the risk for HIV infection? Social contact with a person who has AIDS. Engaging in unprotected sexual encounters. Donation of blood to a local blood bank. Use of public bathroom facilities.

Engaging in unprotected sexual encounters. Rationale: Because human immunodeficiency (HIV) is spread through exposure to blood and bodily fluids, unprotected intercourse and shared drug paraphernalia such as needles remain the highest risks for acquiring HIV. The other activities are not at-risk behaviors for HIV.

A home health nurse is assessing the home environment of an older adult client for safety concerns. Which action should the nurse take? Remove chairs in the living room Ensure extension cords are secured against the wall Close the curtains in areas not being occupied Rearrange all the furniture in the client's bedroom

Ensure extension cords are secured against the wall Rationale: Home safety should be assessed by home health nurses to prevent injuries due to falls. Loose extension cords and wires should be secured and away from walking areas to avoid tripping. Removal of functional furniture is not necessary. The nurse should instruct the client never to climb on chairs to reach objects. Living areas should have good lighting. The older adult is at risk for decreased visual acuity. Rearranging the furniture in the client's room can disorient the client. The only furniture that should be rearranged or removed is one that may cause obstruction or possible injury.

The nurse is assessing a client during the first stage of labor. Which action is correct when evaluating the characteristics of uterine contractions? Evaluate intensity by pressing fingertips into the uterine fundus Assess uterine contractions every 30 minutes throughout the first stage of labor Place a hand on the abdomen below the umbilicus and palpate uterine tone with fingertips Determine frequency by timing the end of one contraction until the end of the next contraction

Evaluate intensity by pressing fingertips into the uterine fundus Rationale: The characteristics of uterine contractions include frequency, duration, and intensity. The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. Duration is how long each contraction lasts from beginning to end. Intensity refers to the strength of the contraction, which is determined by pressing down on the fundus with the fingertips to see if the fundus can be dented. If the fundus can be indented with fingertips at the peak of a contraction, the contraction is deemed mild. It is best practice to time several consecutive contractions before charting frequency or duration.

The nurse is working in a community clinic and receives a call from the parent of a school-aged child. The child was diagnosed with erythema infectiosum (fifth disease) the day before by the child's pediatrician. The parent reports that the child was sent home from school due to the presence of a rash. How should the nurse respond? Tell the parent to bring the child to the clinic for further evaluation Explain to the parent that this rash is not contagious and does not require isolation Send over printed materials about this viral illness to the child's school Instruct the parent to keep the child in isolation at home for 2 to 3 days

Explain to the parent that this rash is not contagious and does not require isolation Rationale: Fifth disease is a viral illness. It begins with cold or flu-like symptoms, and it is at this stage that it is contagious. Once the rash appears, the child is no longer considered contagious. Therefore, the nurse should explain to the parent that the child is not contagious and does not require to be isolated or seen in the clinic. The nurse could send educational materials about fifth disease to the child's school at a later time.

The nurse in a pediatrician's office is performing an assessment on an 8-month-old infant. Which finding should be reported to the health care provider? Toes fan out when the lateral sole of the foot is stroked Falls forward when in a seated position Lifts head from the prone position Rolls from abdomen to back

Falls forward when in a seated position Rationale: The infant should be able to sit unassisted after approximately 6-months-old. The infant falling forward indicates that this developmental milestone has not been met and should be reported to the health care provider. The infant rolling and lifting their head are expected findings. The Babinski reflex is elicited by stroking the lateral sole of the foot from heel to toe. From birth to approximately 12-months-old, the expected response is fanning out of the toes.

The nurse is caring for an older adult client. Which of the following body image changes should the nurse identify as an expected finding for this population? Feeling guilty about wrinkling skin Feeling socially accepted with gray hair Feeling isolated due to mobility changes Feeling happy about increased sensory perception

Feeling socially accepted with gray hair Rationale: The aging adult goes through many physical changes, including the thinning and graying of hair. The client feeling that this change is socially accepted is a positive indication of appropriate body image. Feelings of guilt and isolation are not normal, and older adults experience a decrease in sensory perception rather than an increase.

The clinic nurse is meeting with a client who wants to talk about her and her partner's plan for a future pregnancy. What information is important for the nurse to give to the client? Only the women's medical history should be considered. Immunizations should be avoided at this time. Folic acid should be started before the client has a confirmed pregnancy. All prescribed medications should be continued without concerns.

Folic acid should be started before the client has a confirmed pregnancy. Rationale: Women should start to take folic acid prior to pregnancy to decrease the risk of neural tube defects. Preconception care involves a complete review of both partners' medical history. Medications, supplements, nutrition and psychosocial concerns should be reviewed. Risk factors which impact pregnancy, such as alcohol, drug use, medications, infections, etc., should be identified and avoided. Immunizations should be reviewed and encouraged before pregnancy.

The nurse is caring for a client who has a fractured clavicle and is being discharged home from the emergency department (ED). The client received morphine during this ED admission and is visibly drowsy. When providing discharge teaching, what would be the most appropriate nursing action? Give verbal and written instructions for when to call the provider to both the client and a family member Plan for a follow-up telephone call the next day to provide the discharge teaching to the client Demonstrate to the client's family the application and removal of the sling Give written instructions to the client so they can read when they get home

Give verbal and written instructions for when to call the provider to both the client and a family member Rationale: Before discharge, verbal and written instructions in the client's preferred language are given to the client. The nurse should assess client readiness and include caregivers as learners if a barrier to learning is identified. Discharge teaching is completed prior to the client leaving the ED, so phoning the client the next day to provide initial teaching is not acceptable.

The nurse in a pediatrician's office is assessing a 4-month-old infant's motor skills. Which action by the infant should the nurse expect at this age? Drinking from a cup Grasping a rattle Banging blocks Waving good bye

Grasping a rattle Rationale: A child between the ages of 3 to 6 months should be able to reach and grab things. Grasping a toy, like a rattle, would be an expected finding. The other actions would be seen in older infants. Children between the ages of 6 to 9 months will start to be weaned from the bottle and introduced to a "sippy" cup. Children between the ages of 9 to 12 months may recognize a few familiar sounds, say and wave goodbye, and play more with blocks and other toys.

The nurse is assessing a 3-month-old client's growth and development. Which of the following developmental milestones does the nurse expect to see for this client? Transfers an object from one hand to another Uses thumb and finger to pick up small objects Holds head and chest up when in the prone position Sits upright with support

Holds head and chest up when in the prone position Rationale: At three months old, an expected developmental milestone would be holding the head and chest off the ground while prone. Sitting upright with support is expected at 6-7 months, the pincer grasp is expected at 10 months, and transferring an object from one hand to another is expected at 7 months.

A healthy 18-year-old who is entering college in the fall presents to the clinic for immunizations. Which immunization(s) does the nurse anticipate the health care provider recommending prior to college? Select all that apply. Human papillomavirus (HPV) vaccine Tetanus, Diphtheria, Pertussis vaccine (Tdap) Seasonal influenza vaccine Meningococcal conjugate vaccine (MCV4) Pneumococcal polysaccharide vaccine (PPSV23) Shingles vaccine

Human papillomavirus (HPV) vaccine Tetanus, Diphtheria, Pertussis vaccine (Tdap) Seasonal influenza vaccine Meningococcal conjugate vaccine (MCV4) Rationale: Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to adults older than age 65. The pneumococcal vaccine PCV13 is routinely given to infants/children. An 18-year-old who is going to college should receive the TDAP, MCV4, and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it.

The nurse is admitting a client newly diagnosed with hypertension. Which of the following is the best method for assessing the client's blood pressure? With legs crossed After exercising In both arms With arms hanging down

In both arms Rationale: Accurate blood pressure measurement is essential for diagnosis, management and treatment of hypertension. Not only do health care providers (HCP) need to accurately measure blood pressure, clients need to be taught the correct skill as well. Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed and this results in a false high BP in that arm. All clients should be seated in a straight-back chair with their feet flat on the ground; not crossed, as this could falsely elevate the client's blood pressure. The client's arm should be supported at the mid-sternum level. Having the arm above the heart leads to an underestimation of blood pressure, and below the heart leads to an overestimation of blood pressure. The client should not exercise recently. In addition, they should not drink caffeine or smoke nicotine for at least 30 minutes before their blood pressure is taken.

The postpartum nurse is reviewing the medical record of a client who had a vaginal delivery two hours ago. The record indicates that the client's amniotic membranes ruptured 36 hours before the birth. Which potential postpartum complication is of highest concern for this client? Infection Bleeding Hypoxemia Dehydration

Infection Rationale: Membranes that have been ruptured for more than 24 hours prior to the birth significantly increases the risk of infection to both the mother and the newborn. Therefore, the nurse's highest priority is to assess for signs and symptoms of infection including fever, chills, abdominal pain, foul-smelling lochia, tachycardia and hypotension.

The nurse is assessing a client's cardiovascular system. Which of the following actions by the nurse is appropriate? Palpating both carotid arteries at the same time Auscultating heart sounds at the ninth intercostal space Inspecting the chest wall for heaves or lifts Percussing for a resonant sound over the sternum

Inspecting the chest wall for heaves or lifts Rationale: Inspecting the anterior chest wall heaves or lifts is an important part of a cardiac assessment. Carotid arteries should be palpated one at a time. The ninth intercostal space is not an appropriate location to auscultate heart sounds. Percussion over the sternum will create a flat sound rather than a resonant sound.

A nurse is counseling a client who has a new diagnosis of rotator cuff tendinitis in the left shoulder. Which of the following self-care strategies should the nurse recommend for reducing discomfort? Perform active range of motion exercises Intermittently apply ice to the shoulder Exercise with weights to strengthen the shoulder Sleep with the affected shoulder down

Intermittently apply ice to the shoulder Rationale: Inflammation is present in rotator cuff injuries, so application of ice may help improve discomfort. Repetitive overhead motions can exacerbate shoulder injuries and lead to increased pain. The client should support the affected arm on pillows while sleeping to keep from turning onto the shoulder.

A pregnant client at 34 weeks gestation is diagnosed with a pulmonary embolism. Which of these medications should the nurse plan to administer? Oral warfarin Oral low-dose aspirin Subcutaneous enoxaparin Intravenous heparin

Intravenous heparin Rationale: Clients diagnosed with pulmonary embolism (PE), whether pregnant or not, are initially treated with intravenous unfractionated heparin. Alternatively, low molecular weight heparin such as enoxaparin can be used to treat women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects. Although aspirin has anticoagulant properties, low-dose aspirin therapy (81 mg) is more often used prophylactically, not for the treatment of a PE.

The nurse is assessing a client who is 2 hours postpartum. The nurse suspects the client has subinvolution of the uterus. Which finding should the nurse expect to observe with this client? Vaginal bleeding and uterine protrusion through the introitus Irregular vaginal bleeding and an enlarged uterus Purulent lochia and uterine tenderness Pale mucous membranes and a laterally displaced uterus

Irregular vaginal bleeding and an enlarged uterus Rationale: Subinvolution of the uterus is characterized by sustained enlargement of the uterus and continued lochia discharge. Vaginal bleeding and uterine protrusion through the introitus are indicative of inversion of the uterus. Purulent lochia and uterine tenderness are characteristic of endometritis, an infection that occurs several days postpartum. Pale mucous membranes and a laterally displaced uterus are indicative of uterine atony.

The nurse is teaching a group of women in a community clinic about osteoporosis. Which explanation should the nurse include? It is important to increase calcium intake and weight-bearing exercise. It is best to avoid foods high in purine, such as bacon, liver, and shellfish. Performing regular range-of-motion exercises will help with inflamed joints. Ice, rest, and ibuprofen will help with the symptoms of osteoporosis.

It is important to increase calcium intake and weight-bearing exercise. Rationale: Osteoporosis (OP) is a chronic, progressive metabolic bone disease marked by low bone mass and the deterioration of bone tissue, leading to bone fragility and an increased risk of fractures. Care focuses on proper nutrition, calcium supplementation, exercise, drugs, and the prevention of falls. Osteoporosis is often mistaken for osteoarthritis (OA). Ice, rest, NSAIDs, and range-of-motion exercises are used to treat symptoms of OA and/or rheumatoid arthritis (RA). Purine-rich foods need to be avoided with gout. Purine-rich foods increase uric acid production, which worsens the symptoms of gout.

A 30-month-old child is admitted to the hospital unit. Which of these toys would be most appropriate for this child? Large wooden puzzle Cartoon stickers Blunt scissors and paper Beach ball

Large wooden puzzle Rationale: This child is 2 ½ years old, or 30 months. Appropriate toys for this child's age include items such as dolls and stuffed animals, toy telephone, wooden puzzles, and/or construction toys that snap together. Child's play between the age of 2 and 3 is more purposeful and they have the fine motor skills needed to complete a large wooden puzzle. Children between the ages of 4 to 5 will start to use blunt scissors with art projects; this age is appropriate for safety purposes as well. Cartoon stickers and a beach ball are toys for a younger child between the ages of 1 to 2.

The nurse enters a toddler's hospital room to administer oral medication. When the nurse asks the child, "Are you ready to take your medicine?" the child's response is an immediate, "No!" Which action would be appropriate by the nurse? Notify the health care provider and request a parenteral form of the medication Explain to the child that the medicine must be taken now Ask another nurse to hold the child while giving the medication Leave the room and return five minutes later to try to give the medication

Leave the room and return five minutes later to try to give the medication Rationale: During toddlerhood, a child will begin to display negativism. This negativism is an effort to develop a sense of control and autonomy. By asking the child if they were ready to take the medication, the nurse gave the child a choice. However, toddlers do not have an accurate sense of time, so leaving the room and coming back later is another episode to the toddler, and the child's response may be more positive. The other actions are not appropriate at this time.

The nurse is developing a plan of care for a 14-year-old adolescent with severe scoliosis who is required to wear a thoracic-lumbosacral orthosis brace. Which issue should be the priority? Reliance on the family for social support Lacking independence in physical activities Looking different from their peers Compliance with treatment regimen

Looking different from their peers Rationale: Scoliosis is a lateral curvature of the spine. Treatment of severe scoliosis is long-term and involves bracing either with or without surgery. Being restricted by a brace or surgery is difficult for a child in any developmental stage. The child should be as independent as is safely possible, and nursing care should be focused on educating the client and the family about the benefits of the intervention and positive reinforcement. Conformity to peer influences or pressure peaks around age 14. Because peers may tease, make fun of, or bully the client because of the brace, the priority is to help the client learn how to deal with the reactions of others.

The home health nurse is developing a plan of care for a client with osteoarthritis. What should be the priority goal for this client? Exhibit healthy coping mechanisms Take medications as prescribed Maintain and preserve functional status Maintain a healthy weight

Maintain and preserve functional status Rationale: Osteoarthritis (OA) is the progressive deterioration and loss of cartilage and bone in one or more joints. The client with OA is expected to maintain or improve a level of mobility/functional status and activity that allows him or her to function independently with or without an assistive ambulatory device for as long as possible. Management of the client with OA often requires an interprofessional health team effort. If needed, the nurse should consult and collaborate with the physical therapist (PT) and occupational therapist (OT) to meet the outcome of independent function and mobility. Major interventions include therapeutic exercise and the promotion of ADLs and ambulation by teaching about health and the use of assistive devices.

The home health nurse observes the client change an ileostomy pouch? Which action is best to help prevent skin breakdown? Change the stoma pouch daily Apply antiseptic cream to reddened stoma Use deodorant soaps the contain lotion to clean the stoma Make sure the skin around the stoma is wrinkle-free

Make sure the skin around the stoma is wrinkle-free Rationale: The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leak-free seal.

The nurse is planning a health education class for a community health fair about secondary prevention in health promotion. Which of the following topics should the nurse include in the education? Exercise and nutrition Seatbelts Mammograms and prostate exams Immunizations

Mammograms and prostate exams Rationale: Secondary prevention focuses on preventing the spread of disease, illness, or infection once it occurs. Activities are directed at diagnosis and prompt intervention to reduce severity and enable the client to return to a normal level of health as quickly as possible. Mammograms and prostate exams are screening tests that can lead to early intervention. Primary prevention focuses on preventing disease and illness, like exercise and nutrition, immunizations, and seatbelts.

The nurse is assessing a client in her third trimester of pregnancy. The recent ultrasound suggests the baby is small for the gestational age. However, an earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with which problem? Maternal hypertension Sexually transmitted infection Exposure to teratogens Chromosomal abnormalities

Maternal hypertension Rationale: Maternal hypertension is a common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces the placental exchange of oxygen and nutrients. Chromosomal abnormalities, sexually transmitted infections, and exposure to teratogens are associated with abnormal fetal development in the first trimester.

The parent of an 8-month-old infant asks the nurse if the child's language development is appropriate for this age. Which sounds should the nurse anticipate at this age? Select all that apply. Meaningful words and single vowel sounds such as "ah," "eh," and "uh" Squeals and yells to signal happiness or displeasure Vocalizes in response to voices Babbles in a rhythm similar to spoken language Coos, gurgles, and laughs aloud

Meaningful words and single vowel sounds such as "ah," "eh," and "uh" Squeals and yells to signal happiness or displeasure Vocalizes in response to voices Coos, gurgles, and laughs aloud Rationale: In the first few weeks of life, crying communicates unmet needs for infants. The language developmental milestones are coos and other vocalizations and differentiated crying at 1 to 3 months, simple vowel sounds, such as "ah," "eh," and "uh," at 4 to 5 months, squealing and yelling and imitating speech at 9 to 12 months, and 2 or 3 recognizable words that are connected to meaning and babbling meaningless sounds in a pattern similar to speech at 12 months.

The nurse is caring for a client who has just experienced a miscarriage. Which action should the nurse implement first? Provide information on birth control methods. Monitor the client for bleeding. Refer the client to a grief counselor. Administer Rho(D) to the client.

Monitor the client for bleeding. Rationale: The nurse's priority is to address the client's physical needs (A-B-C) according to Maslow's hierarchy of needs. The nurse must first assess and monitor bleeding and be prepared to act if there is a complication such as a hemorrhage. The other actions are also part of the nurse's plan/implementation but are not the initial priority.

A 15-month-old child presents to the primary care office for follow-up after hospitalization for Kawasaki disease which involved immunoglobulins. The nurse should recognize that which scheduled immunizations will be delayed? Diptheria, tetanus, pertussis (DTaP) Haemophilus Influenzae Type b (Hib) Mumps, measles, rubella (MMR) Inactivated polio vaccine (IPV)

Mumps, measles, rubella (MMR) Rationale: Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body's ability to form antibodies.

he home health nurse is developing a plan of care for a client to self-manage their chronic syndrome of inappropriate antidiuretic hormone (SIADH), due to lung cancer. Which interventions should the nurse include? Select all that apply. Obtain a daily weight Increase intake of foods high in potassium Eliminate foods from the diet that are high in sodium Notify your health care provider for persistent headache and vomiting Restrict fluids to about 1 liter/day Increase fluids to 3 to 4 liters/day

Obtain a daily weight Increase intake of foods high in potassium Notify your health care provider for persistent headache and vomiting Restrict fluids to about 1 liter/day Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) results from an overproduction of ADH or the release of ADH despite normal or low plasma osmolarity. The most common cause is cancer, especially small cell lung cancer. Interventions will focus on treating the underlying cause and managing the fluid/circulatory overload and hyponatremia. Chronic SIADH can be managed at home. Interventions should include daily weights to monitor changes in fluid balance, a fluid restriction of 800 to 1,000 mL/day, adherence to prescribed pharmacotherapy including diuretics and vasopressor receptor antagonists such as conivaptan and tolvaptan, and prevention of electrolyte imbalances (hyponatremia, hypokalemia). A persistent headache and vomiting can indicate an increased intracranial pressure due to fluid overload and should be communicated to the health care provider.

The nurse is assessing a client who recently had a below-the-knee amputation (BKA). The client lives alone and has recently lost their job. Which intervention should the nurse perform to ensure the client's physiological needs are met? Provide the client with a list of support groups Assist the client with researching job opportunities Collaborate with the client's case manager for respite care Obtain a referral for home health care

Obtain a referral for home health care Rationale: Physiological needs refer to basic needs, such as food, sleep, and water. The client lives alone so the nurse should ensure the client has access to basic needs. Home health nurses can assess a client's living situation. Providing the client with support groups meets the social need in Maslow's Hierarchy of Needs. Assisting the client with job opportunities meets safety, not physiological needs. Respite care is used to assist caregivers with the client's needs. The client in this scenario lives alone.

While obtaining the history of a 2-week-old infant during the well-baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24-hours-old. What is the priority nursing action? Schedule the infant for a repeat test in two weeks. Obtain a repeat blood test at this point. Document that the test results are pending. Contact the hospital of birth for the results.

Obtain a repeat blood test at this point. Rationale: Testing for PKU is most reliable when protein has been ingested. A repeat blood specimen must be obtained by the third week of life if the initial specimen was taken from an infant less than 24 hours-old. It is not appropriate to document the results are pending as the specimen was collected when the newborn was less than 24 hours old. It is not necessary to call the hospital for this same reason.

The nurse is caring for a 14-month-old toddler just diagnosed with cystic fibrosis. The parents state this is the first child in either family diagnosed with this disease, and ask about the risk to future children. Which of the following would be the best response by the nurse? One in four chance for each child to carry that trait One in two chance that each child will have the disease One in two chance of avoiding the trait and disease One in four risk for each child to have the disease

One in four risk for each child to have the disease Rationale: Cystic fibrosis (CF) is an autosomal recessive genetic condition that is inherited. A person with a non-functional copy of the gene is a carrier. Carriers for CF have no symptoms, but can pass the gene on to their children. An individual must inherit two non-functioning CF genes, one from each parent, to have CF. In this situation, both parents must be carriers of the trait for the disease because neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, a 50% chance of carrying the trait, and a 25% chance of having neither the trait nor the disease.

The nurse is preparing to complete a physical assessment of an older adult client with limited mobility. Which of the following techniques would be appropriate for this client's assessment? Completing the assessment the same way as they would for a young adult client Asking the client's family member to be present during the assessment Organizing the assessment so that the client does not change positions frequently Avoiding questions that would require the client to discuss their mobility impairment

Organizing the assessment so that the client does not change positions frequently Rationale: Age, developmental status, and physical limitations always need to be considered when performing assessments. Since this client has mobility limitations, the nurse should sequence the assessments so that the client does not have to change positions often. All parts of the assessment need to be completed, but the nurse should be strategic about when each aspect of the assessment is performed. Asking the client's family member to be present is not necessary.

The community health nurse is reviewing the health records of several groups of children. In which age group is noncongenital, idiopathic scoliosis most commonly identified? Infancy Preschool age Preadolescence Early adulthood

Preadolescence Rationale: Scoliosis is a common spinal deformity that can involve lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Scoliosis is classified according to age of onset: congenital (present at birth), infantile (birth up to 3 years of age); juvenile (in children 3 to 10 years of age); and adolescent (occurring at 10 years of age or older). Scoliosis may be caused by a number of conditions and may occur alone or in association with other diseases. In most cases, however, there is no apparent cause, hence the name idiopathic scoliosis. Idiopathic scoliosis is most commonly identified during the preadolescent growth spurt period.

The nurse is providing information to a pregnant client about the potential risks of an amniocentesis. Which risk factors shall the nurse include? Select all that apply. Preeclampsia Premature rupture of membranes Ectopic pregnancy Spontaneous abortion Preterm labor Increase in blood glucose levels

Premature rupture of membranes Spontaneous abortion Preterm labor Rationale: During an amniocentesis, amniotic fluid is removed from the uterus through the insertion of a hollow needle through the abdominal wall and into the uterus. Reasons include genetic testing, fetal lung testing, and removal of excess amniotic fluid (polyhydramnios). Amniocentesis carries various risks, including: leaking amniotic fluid, rupture of amniotic membrane, miscarriage or spontaneous abortion, preterm labor, needle injury to the fetus, Rh sensitization and infection.

The nurse is caring for a female client who is 10-years-old. Which of the following findings would be expected during a physical assessment? Presence of breast buds Pubic hair over mons pubis Lateral curvature of the spine Absence of the two central teeth

Presence of breast buds Rationale: Between ages 9-10 years old, a female will develop breast buds, so this would be a normal finding for a healthy 10-year-old. Pubic hair begins to grow between 11-12 years of age but does not cover the mons until 12-13 years old. The two permanent central incisors should have grown in between the ages of 6-8 years old. Lateral curvature of the spine is an abnormal finding for any age group.

The home health nurse is planning a care conference for the family of a 2-year-old child with cerebral palsy. Which goal should the nurse suggest to the family? Promote the child's optimal development. Prepare the child for independent toileting. Decide on a long-term care facility. Teach the child self-care skills

Promote the child's optimal development. Rationale: The primary goal of nursing care for the child is to promote the child's optimal development. The child should be supported and encouraged to learn and grow to their fullest potential. Self-care and toileting may not be appropriate goals for the child due to the cerebral palsy. It is premature to discuss if the child should be placed in a long-term care facility.

The nurse is teaching a client about primary health prevention. Which of the following actions should the nurse take? Ask the client to complete a screening survey Perform a review of body systems Provide sex education about preventing sexually transmitted infections Assist the client with returning to the highest level of health by providing education

Provide sex education about preventing sexually transmitted infections Rationale: Primary health prevention actions include providing health education about marriage, sex, and genetic screening. Secondary prevention focuses on preventing the spread of disease, illness, or infection once it occurs. Screening surveys and focused examinations to prevent complications are helpful for early diagnosis and prompt treatment. Education and retraining are part of tertiary prevention for restoration and rehabilitation to minimize the effects of long-term disease or disability.

The nurse is preparing to inspect the tympanic membrane of a 2-year-old client. Which technique by the nurse is appropriate? Lifting the pinna up and back once the otoscope has been inserted Instructing the client to hold their breath while the otoscope is used Inserting the otoscope while the child is laying in the prone position Pulling the pinna down slightly before inserting the otoscope

Pulling the pinna down slightly before inserting the otoscope Rationale: For young children, the pinna should be pulled straight down prior to inserting the otoscope. This action allows the ear canal to straighten and allows the examiner to view the tympanic membrane more easily. Holding breath is not necessary, and the client should be upright during this exam.

The nurse is caring for older adults who live in a long-term care setting. Which activity would most effectively meet the growth and developmental needs for older adults? Transportation for shopping trips Reminiscence groups Aerobic exercise classes Regularly scheduled social activities

Rationale: According to Erikson's theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of the elderly as "ego integrity versus despair."

A 72-year-old client is admitted for possible dehydration. The nurse knows that older adults are particularly at risk for dehydration due to which physiologic change? A A decreased metabolic rate B A decreased sensation of thirst Correct Answer (Blank) C An increased need for extravascular fluid D An increase in diaphoresis

Rationale: Older adults have a reduction in thirst sensation, and this causes them to consume fewer fluids. Other risk factors may include fear of incontinence, inability to drink fluids independently, increased frequency to void with increased fluid intake, and lack of motivation.

The nurse is evaluating a toddler's readiness for toilet training. Which milestones should the nurse assess to determine the readiness of the child? Select all that apply. Recognition of the urge to defecate or urinate Parents willing to invest the time needed to teach the child Ability to have a dry diaper for two hours and wake from a nap with a dry diaper Ability to button clothing when dressing themselves Fine motor development enough to be able to remove clothing

Recognition of the urge to defecate or urinate Parents willing to invest the time needed to teach the child Ability to have a dry diaper for two hours and wake from a nap with a dry diaper Fine motor development enough to be able to remove clothing Rationale: The nurse should provide guidance to parents concerning toilet training. This discussion should begin at a child's routine visit to a health care provider. The parents should be given information and supported through the potentially frustrating time of toilet training. The nurse should evaluate the toddler's and parents' readiness or educate the parents on signs that the child is ready to begin toilet training. The child should wake from a nap with a dry diaper and be able to have a clean diaper for two hours. The child should be able to begin removing clothes. However, the clothing worn by the child should be easy to remove. The child will need to be able to recognize the urge to defecate or urinate. The parents should understand that this could be a time-consuming and frustrating process. The child may display the ability to remove clothing. However, the child may not have the fine motor skills to button clothing after toileting.

The homecare nurse is caring for an older adult following knee replacement surgery one week ago. The client has multiple long-standing prescriptions for chronic conditions and has been having episodes of dizziness occasionally for several years. Which of the following interventions is the nurse's priority? Recommend the client sleep in the downstairs bedroom Perform medication reconciliation to ensure the client is not experiencing an adverse drug event Educate the client on disease management Observe the client perform the prescribed physical therapy exercises

Recommend the client sleep in the downstairs bedroom Rationale: Polypharmacy and loss of balance are major contributors to falls. Climbing stairs may prove challenging for the client who is experiencing pain and weakness. Throw rugs pose a risk of tripping. The client's acute risk for falls takes priority over the management of chronic conditions at this time. Observing the client perform the exercises is important but not the priority.

The nurse measures the head and chest circumference of an 18-month-old infant. When comparing the data, the nurse notes the two measurements are the same. What action should the nurse take next? Record the findings in the chart Palpate the anterior fontanel Feel the posterior fontanel Notify the health care provider

Record the findings in the chart Rationale: These are expected findings, and the nurse will record the measurements in the client's chart. Between 6 months and 2 years, an infant's head circumference and chest circumference measurements are about the same. A newborn's head is usually about 2 centimeters larger than the chest size; after age 2 years, the chest size becomes larger than the head.

The nurse is assessing a 1-day-old newborn infant. The nurse notices that the infant's breasts are enlarged bilaterally with a thin, white discharge. Which action by the nurse is appropriate? Obtain a specimen of the fluid to check for glucose. Record the findings, noting they are normal. Notify the health care provider immediately. Ask the mother about medications taken during pregnancy.

Record the findings, noting they are normal. Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to weeks after birth. This is a result of circulating maternal hormones after birth. This typically resolves on its own in the first few weeks after birth.

The nurse has been caring for the same client for 5 days. The client has been exhibiting manipulative behaviors. The nurse becomes aware of feeling reluctant to interact and care for the client. Which action should the nurse take? Talk with the client about the negative effects of their manipulative behaviors. Report the feelings of reluctance to an objective peer or supervisor. Develop a behavior modification plan for the client. Limit contact with the client to avoid reinforcement of the behaviors.

Report the feelings of reluctance to an objective peer or supervisor. Rationale: The nurse who experiences stress in a professional relationship with a client can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of reactions that can influence the nurse-client relationship in positive and negative ways.

The nurse at a hypertension clinic has been teaching adult clients about modifiable risk factors. Which client response would best indicate that the teaching was effective? Responses to verbal questions Reported behavioral changes Performance on written tests Completion of a mailed survey

Reported behavioral changes Rationale: If the clients alter behaviors such as smoking, drinking alcohol and stress management, these changes suggest that learning has occurred. Additionally, physical assessments, observed behaviors and laboratory data (e.g., blood tests) may confirm risk reduction.

The nurse is counseling an older adult who has total care of the spouse and suffers from a debilitating condition. The couple voices concern over the effect that caregiver burden has on the physical and emotional health of the caregiver. What type of care might the nurse include in the counseling? Palliative care Bereavement care Respite care Hospice care

Respite care Rationale: The main purpose of respite care is to give the primary caregiver some time away from the responsibilities of day-to-day care. This can occur in an adult day care center or in the patient's home. Nurses provide information about how to access respite care and may make referrals. Hospice is a program providing physical, psychological, social, and spiritual care for dying people, their families, and other loved ones. Palliative care exists within and outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is patient- and family-centered care that optimizes the quality of life by anticipating, preventing, and treating suffering. Bereavement care is provided to families following the death of a family member.

The nurse is planning care for several clients in the labor and delivery unit. Which mother-baby pair would the nurse identify as needing a Coombs test? Rh-positive mother with Rh-positive baby Rh-negative mother with Rh-positive baby Rh-positive mother with Rh-negative baby Rh-negative mother with Rh-negative baby

Rh-negative mother with Rh-positive baby Rationale: An Rh-negative mother who delivers an Rh-positive baby may develop antibodies to the fetal red blood cells. The mother may have been exposed during pregnancy or placental separation. Rh-positive mothers do not require this test or treatment with RhIG (RhoGAM). RhIG is indicated for intramuscular injection to Rh-negative women with a negative Coombs test. The administration of RhIg at 26 to 28 weeks of gestation further reduces the risk of Rh incompatibility (isoimmunization).

A parent asks about expected motor skill development for their 3-year-old child. Which activity is considered a typical motor skill for that age? Riding a tricycle Jumping rope Tying shoelaces Playing hopscotch

Riding a tricycle Rationale: 3-year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include peddling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and fine motor skills that are more typical for older children.

The nurse is caring for an adolescent after an injury from a fall who has a history of hemophilia A. While preparing to provide education, which statement should be emphasized to clients diagnosed with this condition? Alternative sedentary and structured activities should be discussed Physical limitations must be explained to peer groups Implications of taking risks after acute bleeding episodes should be emphasized Safely exercising and taking part in sports are important

Safely exercising and taking part in sports are important Rationale: An age-appropriate treatment goal is to establish an age-appropriate safe environment. Adolescents diagnosed with hemophilia should be aware that contact sports may trigger bleeding episodes. However, developmental characteristics of this age group, such as impulsivity, inexperience, and peer pressure, place adolescents in unsafe environments.

The clinic nurse is evaluating an older male client who reports having trouble urinating. After the client uses the bathroom, which method should the nurse use to check for post-void residual (PVR)? Check for rebound tenderness in the lower abdomen Palpate for rounded swelling above the pubic bone Scan the bladder using a portable ultrasound scanner Insert an intermittent urinary catheter (straight catheterization)

Scan the bladder using a portable ultrasound scanner Rationale: Urinary retention and incomplete bladder emptying can result from urethral obstruction, as seen in benign prostatic hyperplasia (BPH). The nurse can palpate the area from the umbilicus towards the symphysis pubis. An empty bladder rests behind the symphysis pubis and should not be palpable. The nurse can also percuss this area. A urine-filled bladder produces a dull sound, but a bladder ultrasound is the most effective technique since it will digitally register bladder volume. Routine catheterization to check for PVR is not recommended. Abdominal rebound tenderness will not determine urinary retention.

The nurse is reviewing the lab results of a full term, 30-hour-old newborn infant. The nurse knows that the first-time mother is Rh negative. Which of these findings is the priority to report to the health care provider? Hematocrit of 52% Apgar score of 8 at birth Jaundice is observed Serum bilirubin of 11 mg/dL

Serum bilirubin of 11 mg/dL Rationale: Jaundice is a common condition in newborns. But for a full-term infant who is 30 hours-old, a total serum bilirubin level of 11 mg/dL is high, indicating the possibility of hemolysis due to Rh incompatibility. The concern about hyperbilirubinemia is increased because the mother is Rh negative. Therefore, that finding is the priority finding to report to the health care provider. The other findings are either normal (hematocrit) or not as important at this time.

A nurse in an obstetrics clinic is taking a health history from a 40-year-old woman in the first trimester of pregnancy. Which information from the health history requires priority follow-up from the nurse? She has been taking an ACE inhibitor for her blood pressure for the past 2 years. Her partner was treated for tuberculosis as a child. Her father and brother have type 1 diabetes. She has been taking 800 mcg of folic acid daily for the past year.

She has been taking an ACE inhibitor for her blood pressure for the past 2 years. Rationale: A report by the client that she has been taking medications in the first trimester of pregnancy should be the priority to follow-up on. ACE inhibitors are pregnancy category X, as they may cause teratogenic effects on the developing fetus and increase the risk of birth defects. The nurse should notify the primary health care provider (HCP) of this pertinent information. Folic acid is recommended to take during pregnancy to aid in fetal neurological development. While the family history of diabetes and tuberculosis are important to note, the priority is the ACE inhibitor that the client is taking because it may be affecting fetal development.

The nurse is reviewing the laboratory data for a client who is 10 weeks gestation. The nurse notes the following results: hemoglobin level of 9.8 g/dL, rubella titer positive, urine glucose level of 0 mmol/dL, and nontreponemal tests (venereal disease research laboratory [VDRL]) negative. Based on the results, which education should the nurse provide to the client? Side effects of iron supplements and food sources of iron Scheduling for the rubella vaccine Necessity of completing the entire prescription for penicillin Steps for completing the oral glucose tolerance test (GTT)

Side effects of iron supplements and food sources of iron Rationale: Iron deficiency is the most common pathologic cause of anemia in pregnancy. Increased risk during pregnancy is due to increased maternal iron needs and demands from the growing fetus, and, in the third trimester, expanded maternal blood volume. The consequences of iron-deficiency anemia include preterm delivery, perinatal mortality, and postpartum depression. Neonatal consequences include low birth weight and poor mental and psychomotor performance. Nursing management of the woman with iron-deficiency anemia focuses on encouraging adherence to iron therapy and providing dietary instruction about the intake of iron-rich foods. The client has a positive rubella titer, indicating immunity. Therefore, a booster is not required. The nontreponemal tests were negative, indicating the client has no antibodies to syphilis and does not require antibiotics. There is no glucose in the urine and, therefore, no indication of diabetes. The GTT will be administered in the first part of the third trimester to screen for gestational diabetes.

The nurse is interviewing a client to obtain the client's medical history. Which action by the nurse is appropriate to ensure effective communication? Document the client's history during the interview Sit at the client's eye level during the interview Maintain a distance of two to three feet away from the client Invite other healthcare providers to witness the interview

Sit at the client's eye level during the interview Rationale: Sitting at the client's eye level is an effective technique to establish trust and show equal authority status. Interviews should be conducted at a distance of 4-5 feet, and documenting while the client is speaking may indicate to the client that the examiner is not actively listening. In most cases, interviews should occur with one client and one examiner; having multiple providers in the room may intimidate the client.

During a routine visit, the nurse is evaluating developmental milestones for a 7-month-old child. Which of these developmental activities should the child be able to perform? Says several words Uses a neat pincer grasp Drinks from a cup Sits leaning on hands for support

Sits leaning on hands for support Rationale: The age at which a child typically develops the ability to sit while supporting themselves is around 7 months. Around 8 months, the child should be able to sit erect without support. Saying several words, drinking from a cup, and using a neat pincer grasp are developmental milestones that most children do not reach until age 11-12 months. Fine motor behavior, such as grasping an object, develops in stages. The palmar grasp of the newborn develops into a crude pincher grasp at 8 to 10 months of age and a neat pincher grasp around 11 months of age.

A pregnant woman in the third trimester of pregnancy calls the clinic nurse and reports having severe heartburn. Which initial intervention should the nurse recommend to the client? Sleep with the head elevated on pillows Take an antacid between meals Increase intake of foods high in fiber Drink frequent small amounts of liquids

Sleep with the head elevated on pillows Rationale: Heartburn (indigestion) is a common occurrence during pregnancy especially in the later trimesters. Progesterone slows GI motility and relaxes the cardiac sphincter; in addition, the stomach is displaced upward and compressed by the enlarging uterus. An initial, non-invasive, easily implemented intervention is to sleep with the head/upper body elevated. Taking antacids between meals would be an intervention that the health care provider needs to approve and prescribe. There is no evidence that frequent sips of water or increased fiber intake will reduce heartburn.

The nurse is screening clients at a local clinic for chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following results? Spirometry did not improve after receiving an inhaled bronchodilator Computed tomography (CT) scan shows bronchial dilation. Alpha1-antitrypsin levels are elevated. Serum IgE levels are elevated.

Spirometry did not improve after receiving an inhaled bronchodilator. Rationale: Spirometry is when a client is asked to empty the lungs completely with force and a measurement is obtained. This evaluates airflow obstruction by determining the ratio of FEV1 to forced vital capacity (FVC). Genetic risk for COPD is Alpha1-antitrypsin deficiency. A CT scan showing bronchial dilation can indicate bronchiectasis. During an asthma attack caused by allergies, the client's serum IgE levels will be elevated.

The nurse is assessing a 3-year-old client's growth and development. Which of the following actions is an expected finding for the child's developmental level? Ties shoelaces Buttons up a shirt Reads time from a clock Stacks a tower of blocks

Stacks a tower of blocks Rationale: At 3 years old, an expected developmental milestone would be the ability to stack multiple blocks vertically. Tying shoelaces is expected at 5 years old, simple buttoning is expected at 4 years old, and reading a clock is not expected until 7 years old.

The nurse is assessing the growth and development of a 9-year-old child. Which finding indicates that the child has attained the development stage of concrete operations, according to Piaget? The child thinks in mental images or word pictures. The child reasons that homework is time-consuming but necessary. The child explores the environment with the use of sight and movement. The child verbalizes understanding that stealing is wrong.

The child verbalizes understanding that stealing is wrong. Rationale: According to Piaget's theory of cognitive development in children, the stage of concrete operations is characterized by logical thinking and moral judgments. This stage is associated with school-aged children from about age 7 to 11. Exploring the environment is seen in the sensorimotor stage (birth to 24 months). Mental symbolization is seen in the preoperational stage (2 to 4 years). Formal operational thought is seen with adolescents, who might reason that homework is time-consuming but necessary.

The nurse is assessing an 18-month-old client at a well visit. Which of the following findings indicates that the client is experiencing growth or developmental delays? The client has a total of eight teeth. The client cannot state their full name. The client mimics household chores. The client cannot stack two blocks

The client cannot stack two blocks Rationale: A toddler should be able to stack two blocks at 15 months old; not having the motor control to complete this action indicates a developmental delay. At 18-months-old, a toddler can say 7-20 simple words, but asking the child to state their full name is not expected. At 18 months old, 8-10 teeth are expected, and imitation of chores is a typical play activity at this age.

The nurse is obtaining a health history from a female client who has a family history of breast cancer. Which of the following findings would increase the client's risk? The client breast-fed for one month after pregnancy. The client has a history of multiple episodes of mastitis. The client started menses at age 14. The client had her first full-term pregnancy at age 33.

The client had her first full-term pregnancy at age 33. Rationale: Risk factors for breast cancer can include late age (after age 30) at first full-term pregnancy and early menarche (before age 12). Not breastfeeding increases the client's risk for ovarian cancer. Mastitis is not a risk factor for cancer.

Question 4 Which information in a client's history would place them at an increased risk for skin cancer? Select all that apply. The client is receiving an immunosuppressant drug. The client's profession is fisherman. The client is dark-skinned. The client has blond hair and green eyes. The client is 65-years-old.

The client has blond hair and green eyes. The client is 65-years-old. Rationale: A client with fair skin tone, blond or red hair and blue or green eyes are at increased risk for skin cancer. People who work outdoors (e.g., fishermen, farmers, bridge construction workers) are exposed to increased sunlight and ultraviolet light. Age risk factors are adults younger than 30 years and older than 50 years old. Risk of squamous cell skin carcinoma is increased for individuals receiving immunosuppressant drug therapy. Other risk factors include a previous history of sunburns, indoor tanning and family history of skin cancer.

The nurse in an obstetrics clinic is reviewing the medical record of a currently pregnant client with a GTPAL history of 3-2-0-1-2. How should the nurse interpret the GTPAL score? The client has been pregnant a total of four times. The client has three living children. The client has had two term births. The client has not had any miscarriages.

The client has had two term births. Rationale: The GTPAL system calculates the obstetric history of a woman in terms of the number of times she has been pregnant (Gravidity), the number of Term births she has had, the number of Premature births she has had, the number of Abortions or miscarriages she has had, and the number of Living children she currently has. A GTPAL score of 3-2-0-1-2 indicates 3 pregnancies (including the current one), 2 term births, 0 preterm births, 1 miscarriage/abortion and 2 living children.

The nurse is screening an 80-year-old female client for causes of hypertension. Which of the following should the nurse identify as a possible cause? The client's age The client's gender The client has obstructive sleep apnea The client has a history of asthma

The client has obstructive sleep apnea Rationale: Obstructive sleep apnea can cause hypertension. A sympathetic response is triggered by the frequent apneic events that cause hypoxia and hypercapnia. These clients also have a high risk for myocardial infarction and stroke. The client's age and gender are not risk factors for hypertension. The disease process of asthma does not cause hypertension. It is possible for the client's blood pressure to increase from medications used to treat asthma, but that would not be diagnosed as hypertension, rather just an increased blood pressure as a side effect of the medications.

The nurse is caring for a client with cancer who is receiving healing touch alternative therapy. Which finding would indicate to the nurse that the treatment is effective? The client routinely asks for the prescribed oxycontin every 4 hours. The client takes several naps during the day. The client reports feeling less anxious today. The client denies chills or shivering.

The client reports feeling less anxious today. Rationale: Clients who receive Healing Touch (HT) may sleep better, have their pain and anxiety are reduced, have their medications work longer and better, and may not need as many pain medications. HT does not reduce the risk of infection and would promote daytime wakefulness due to increased rest at night.

A nurse working in an oncology clinic recommends ginger to certain clients receiving chemotherapy. What findings would indicate that the herb is having the intended effect? The client says they can sleep through the night without interruption. The client feels like they have more energy now than just a few weeks ago. The client reports less nausea and vomiting after this round of chemotherapy. The client says they are less forgetful since they started taking the herb.

The client reports less nausea and vomiting after this round of chemotherapy. Rationale: Clinical trials indicate that ginger can effectively reduce nausea and vomiting associated with chemotherapy, motion sickness, pregnancy, and surgery. Research does not support the other options.

The nurse is caring for a client who has a subdermal hormone implanted in the upper arm for family planning. Which of the following is an expected outcome for this method of contraception? The client expresses a desire to remove the implant. The client experiences an increase in libido. The client experiences no signs or symptoms of sexually transmitted infections. The client voices satisfaction with this method of family planning.

The client voices satisfaction with this method of family planning. Rationale: Expected outcomes for contraception not only include the method's effectiveness but also correct use of the method and satisfaction with the method. An increase in libido should not be listed as an expected outcome, as hormonal contraceptives often decrease libido. The subdermal implant provides no protection from STIs, and the client asking to remove the implant indicates that they are dissatisfied with the method.

The clinic health nurse is reviewing the medical records of a group of female clients. The nurse would include a recommendation for hormonal emergency contraception in which of the following situations? The client who reports consistently taking oral contraceptives who had unprotected intercourse with a new partner yesterday The client with an intrauterine device who reports having a condom break during intercourse two days ago The client who reports on Thursday that she missed two doses of her oral contraceptive pills after having intercourse on Saturday The client who reports missing her daily dose of oral contraceptive the same day she had unprotected intercourse

The client who reports missing her daily dose of oral contraceptive the same day she had unprotected intercourse Rationale: Emergency contraception (EC) reduces the risk of pregnancy after unprotected intercourse or contraceptive failure, such as condom breakage. It is used within 72 hours of unprotected intercourse to prevent pregnancy. The sooner ECs are taken, the more effective they are. They reduce the risk of pregnancy for a single act of unprotected sex by almost 80%. The client who reports missing her daily dose of oral contraceptive (yesterday or the day before) and had unprotected sex (same day) would require education on EC.

A nurse is establishing health promotion goals for a client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following long-term outcomes should the nurse include in the plan of care? The client will be provided with smoking cessation options during the initial counseling session. The client will have a decrease in BMI by the three-month follow-up appointment. The client will stop smoking within one week of the initial counseling session. The client will select an approved nutrition plan during the initial teaching session.

The client will be provided with smoking cessation options during the initial counseling session. Rationale: Goals, outcomes, and objectives are all terms used interchangeably during the planning process to develop outcomes that can be measured during the evaluation phase of the nursing process. Nurses develop patient goals/outcomes that are specific, measurable, attainable, realistic, and time-bound in collaboration with a client. Short-term goals may be achieved during a teaching session, but long-term goals may require weekly or monthly visits.

The nurse is caring for a primigravida client who is in active labor. Which assessment finding may be an early indication that the client is developing a complication of the labor process? The mother's blood pressure is 138/88 mmHg. The mother's temperature is 100° F (37.7° C). The cervical dilation is measuring 4 cm. The fetal heart rate has been around 180 bpm for several minutes.

The fetal heart rate has been around 180 bpm for several minutes. Rationale: The finding that indicates a possible complication of the labor process is the fetal heart rate of 180 bpm for several minutes. The normal fetal heart rate is typically somewhere between 120 and 160 bpm. Although the heart rate will fluctuate during labor and between contractions, prolonged fetal tachycardia can be an early sign of hypoxia.

The nurse is assessing clients at a community center for lifestyle practices that increase the risk of cancer. Which of the following findings should the nurse identify as a significant risk? Exercising 30 minutes per day Drinking two caffeinated beverages per day Consuming 2000 mg of sodium each day Using smokeless tobacco once a day

Using smokeless tobacco once a day Rationale: Tobacco use in any form increases a client's risk for cancer significantly. Fifteen minutes of exercise and two caffeinated beverages do not increase the risk for cancer. The U.S. Department of Health recommends that a person consume less than 2300 milligrams of sodium per day, so 2000 milligrams is within these recommendations.

A nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the newborn. What observation at the time of discharge suggests that initial breast-feeding teaching has been effective? The newborn refuses the supplemental bottle of glucose water. The mother feels calmer and talks to the baby while nursing. The mother awakens the newborn to feed whenever it falls asleep. The newborn falls asleep after three minutes at the breast.

The mother feels calmer and talks to the baby while nursing. Rationale: Early evaluation of successful breast-feeding can be measured by the client's voiced confidence and satisfaction with the neonate. Refusing supplemental glucose water does not indicate successful breastfeeding. Falling asleep within a few minutes of latching, the infant is likely not getting enough milk.

An 18-month-old child is awaiting a renal transplant. When reviewing the child's health history, the nurse notes that the child has not had the first measles, mumps, rubella (MMR) immunization. Which action should the nurse take? An inactivated form of the vaccine can be given at any time. Live vaccines are withheld in children with renal chronic illness. The risk of the vaccine's side effects are too great and it should not be given. The vaccine should be given now, before the transplant.

The vaccine should be given now, before the transplant. Rationale: The measles, mumps and rubella (MMR) vaccine is a live virus vaccine, and should be given at this time, pre-transplant. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the child's compromised immune system.

The nurse is teaching a smoking cessation class and notices that there are two pregnant women in the group. Which information is a priority for these women? Moderate smoking is effective in weight control. The placenta serves as a barrier to nicotine. Low tar cigarettes are less harmful during pregnancy. There is a relationship between smoking and low birth weight.

There is a relationship between smoking and low birth weight. Rationale: Nicotine reduces placental blood flow and may contribute to fetal hypoxia or placenta previa, which results in the decreased growth potential of the fetus. Nicotine readily crosses the placenta, and any form of nicotine should be avoided during pregnancy.

A client with high risk for metabolic syndrome was referred to a registered dietician for nutritional counseling. The nurse is evaluating the client's progress. Which finding demonstrates the counseling was effective? Systolic blood pressure of 135 mmHg Triglyceride level of 147 mg/dL Fasting blood glucose level of 102 mg/dL High density lipoprotein (HDL) level of 39 mg/dL

Triglyceride level of 147 mg/dL Rationale: Metabolic syndrome is characterized by abdominal obesity, high triglyceride levels, low high-density lipoprotein (HDL) levels, increased blood pressure, and increased fasting blood glucose. The expected finding after dietary changes is a triglyceride level below 150 mg/dL. The systolic blood pressure should be less than 130 mmHg. The fasting blood glucose level should be below 100 mg/dL. The HDL level for males should be greater than 40 mg/dL and greater than 50 mg/dL for females.

The nurse is evaluating the growth of a 12-month-old child. Which finding would the nurse expect to be present in the child? Two deciduous teeth Head is greater than the chest circumference Increased 10% in height Tripled the birth weight

Tripled the birth weight Rationale: The birth weight usually triples by the end of the first year of life. Height usually increases by 50% from birth length. A 12-month-old child should have approximately six teeth; estimate the number of teeth by subtracting 6 from the age in months (12 - 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.

The nurse is assessing a client in early labor. While positioning the client to perform a vaginal exam, the client reports feeling dizzy and nauseous. The client appears pale and has low blood pressure. Which action should the nurse take initially? Encourage deep breathing Call the health provider Turn her to her left side Elevate the foot of the bed

Turn her to her left side Rationale: While in the supine position, the weight of the uterus can put pressure on the vena cava and aorta. The client is experiencing symptoms of hypotension and dizziness due to constriction of blood flow. To relieve the pressure on the vena cava and aorta, the nurse should initially turn the client to the left side to reduce pressure and relieve postural hypotension.

When assessing vital signs in children, the nurse knows that the apical pulse is preferred until the radial pulse can be accurately assessed at about what age? One year Three years Two years Four years

Two years Rationale: A child should be at least 2 years old to use the radial pulse to assess heart rate.

The nurse is planning to provide community health education. Which of the following actions should be the priority when planning the education session? Creating relationships with the population being educated Understanding the health needs of the population being educated Evaluating the health services already available in the population being educated Determining the average education level of the population being educated

Understanding the health needs of the population being educated Rationale: Assessment of health care needs of individuals, families, and communities is the first component in achieving healthy populations and communities. The nurse needs to understand the needs of the specific population being educated. Once the needs are understood, then the nurse can create relationships and build rapport by demonstrating that the nurse is aware of the needs of the community. The nurse will also build relationships while interviewing the population to assess the needs. Evaluating the services available and issues related to the services and determining learning needs and barriers are also important but not a priority over the needs of the population.

A community health nurse is teaching a new parent group about primary prevention of lead poisoning in children. Which intervention should the nurse include? Request chelation therapy from the child's pediatrician. Monitor the child for developmental delays. Boil tap water for 10 minutes prior to adding to formula or food. Use bottled water to add to any formula concentrate or powder.

Use bottled water to add to any formula concentrate or powder. Rationale: Lead exposure to children can result from multiple sources and can cause irreversible and life-long health effects. No safe blood lead level in children has been identified. Even low levels of lead in blood have been shown to affect IQ, ability to pay attention and academic achievement. Lead-contaminated water continues to pose a risk for many communities in the United States. Drinking water may become contaminated by lead from old lead pipes or the lead solder used in sealing the water pipes in older communities, building and homes. To reduce the risk of lead poisoning in infants in communities at risk for lead-contaminated water, a preventative intervention is to use bottled water to prepare formula from concentrate or powder. Boiling water will kill bacteria in water but does not remove the lead. Developmental delays are an outcome of lead poisoning, not a preventative measure. Chelation therapy is a treatment option for children diagnosed with high serum levels of lead; it is not a preventative treatment.

The community health nurse is teaching a group of parents about the negative or oppositional behavior typically seen during toddlerhood. What would be the best intervention for this behavior? Use patience and a sense of humor to deal with this behavior Offer the child a reward such as sweets to stop the behavior Assert authority over the child through strict limit setting Reprimand the child and give them a 15-minute "time out"

Use patience and a sense of humor to deal with this behavior Rationale: With anticipatory guidance regarding expected but challenging behaviors and situations during toddlerhood, parents may need assistance in providing limits that prevent normal, disruptive behaviors, such as temper tantrums, from becoming problems. Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As toddlers attempt to express their will, they often give a negative response to requests. The word "no" can be the sole vocabulary. If scolded for doing something wrong, they can have a temper tantrum and almost instantaneously pull at the parent's legs to be picked up and comforted. Understanding and coping with these swift emotional changes is often difficult for parents. Many parents find the negativism very frustrating and tend to give in to it, which further threatens the child's search for acceptable methods of interacting with others. A less authoritative or confrontational approach such as using patience and humor tends to work best in those situations.

The nurse is discharging a 6-year-old child diagnosed with recurrent urinary tract infections (UTIs). Which of the following is the most appropriate instruction to give the caregiver? Use plain water for the bath and shampoo the hair last. When laundering clothing, rinse several times. Have the child use antibacterial soaps while bathing. Increase bladder tone by delaying voiding.

Use plain water for the bath and shampoo the hair last. Rationale: Management of urinary tract infections includes hygiene practices. This includes using plain water for the bath and to shampoo the hair last, and rinse the genital area with plain water after shampoo is rinsed from the hair. The child should not delay voiding as this could promote UTIs. It is not necessary to rinse the laundry several times or use antibacterial soaps.

The nurse is assessing the growth and development of a 24-month-old client. Which of the following actions by the client indicates age-appropriate development? Uses simple two-word sentences Pulls up from sitting to standing Crawls up stairs using hands and feet Babbles vowel sounds

Uses simple two-word sentences Rationale: At 24 months old, an expected developmental milestone would be the use of two-word sentences, often a noun and a verb. Pulling up from sitting is expected at 10 months, creeping/crawling up stairs is expected at 15 months, and babbling vowel sounds is expected at 6 months.

The nurse is assessing a client who is 6 hours postpartum. The client's heart rate is 112 beats/min, and she has pale mucous membranes. The nurse notes bogginess of the uterus upon palpation. Which complication should the nurse suspect the client is experiencing? Uterine atony Pulmonary embolism Disseminated intravascular coagulation (DIC) Inversion of the uterus

Uterine atony Rationale: Uterine atony is a postpartum complication resulting from the inability of the uterine muscle to contract after giving birth. This can lead to increased vaginal bleeding, a boggy uterus, and tachycardia. A pulmonary embolism results from a dislodged deep vein thrombosis. Although tachycardia is a sign, a boggy uterus is not expected. Disseminated intravascular coagulation (DIC) results in uncontrolled clotting and bleeding. Tachycardia and pallor are common; however, a boggy uterus is not consistent with this complication. Inversion of the uterus occurs when the uterus is turned inside out and visible through the introitus.

The nurse is caring for a woman in active labor. An internal fetal heart rate monitoring wire is in place. Which fetal heart rate pattern indicates a possible complication of labor? Early decelerations Variable decelerations Periodic accelerations Late accelerations

Variable decelerations Rationale: A deceleration in fetal heart rate (FHR) may be benign or abnormal. Variable decelerations in FHR are often indicative of an interruption in the fetal oxygen supply due to umbilical cord compression. This is a complication that should be reported to the health care provider immediately.

A nurse is assigned to a 12-year-old diagnosed with an acute illness. Which approach indicates that the nurse understands common sibling reactions to hospitalization? Visitation is helpful for both. The siblings may enjoy privacy. Those cared for at home cope better. Younger siblings adapt very well.

Visitation is helpful for both. Rationale: When a child is hospitalized, it impacts the entire family. The sibling(s) at home may be scared and fearful about what is happening with the hospitalized sibling. Some of these stressors can be reduced by a hospital visit. The hospitalized sibling may be lonely and having sibling(s) visit can help with that. While the siblings may enjoy privacy, this may not be appropriate depending on the condition of the sibling; Each child manages differently, thus the nurse cannot know how a younger sibling may adapt to the hospitalization of their sibling.

The nurse is caring for a client who has a prescription for daily weight measurements. Which of the following actions by the nurse is appropriate? Removing the client's clothing prior to measuring weight Weighing the client at the same time each day Measuring the client's weight while taking vital signs Alternating the scale from the previous day

Weighing the client at the same time each day Rationale: To ensure accuracy, the nurse should weigh the client at the same time each day and use the same scale as previous weight measurements. The client does not need to remove clothing unless a particular item of clothing is bulky or heavy. The client should be wearing clothing that is similar to the items worn during previous weight measurements. The nurse should not perform any additional assessments while the weight is being measured.

The nurse in a pediatrician's office is assessing the growth of children during their school-age years. Which finding is normal for this age group? Weight gain of about 4 to 6 lb (2 to 3 kg) per year Progressive height increase of 4 inches each year Little change in body appearance from year to year Decreasing amounts of body fat and muscle mass

Weight gain of about 4 to 6 lb (2 to 3 kg) per year Rationale: The segment of the life span that extends from age 6 years to approximately age 12 years has a variety of labels, but is most often referred to as school-age or the school years. Between ages 6 and 12 years, children grow an average of 5 cm (2 inches) per year to gain 30 to 60 cm (1 to 2 feet) in height and will almost double in weight, increasing 2 to 3 kg (4.4 to 6.6 lb) per year.

A local school had an increased incidence of pediculosis capitis in the past week. The school nurse plans a screening of all children. Which manifestation observed by the nurse would confirm the presence of pediculosis capitis? Whitish oval specks sticking to the hair shaft White flakes on the student's shoulders Scratching the head more than usual An oval pattern of occipital hair loss

Whitish oval specks sticking to the hair shaft Rationale: Diagnosis of pediculosis capitis, or head lice, is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include the application of a medicated shampoo with lindane for children over two years old and meticulous combing with a special comb for the removal of all nits. White flakes would most likely be dandruff or dried hair product. Dandruff is easily distinguished from nits because dandruff does not attach to the hair shaft and is easily removed. While head lice could cause head-scratching, but it can also be attributed to other causes. An oval pattern of hair loss can be caused by many different things, including tinea capitis (ringworm) and hair shaft trauma (child pulling out the hair). The nurse should explain to the children that anyone can get head lice, and lice are transmitted from one person to another by the use of personal items such as combs, hair ornaments, scarfs, or hats.