Health promotion

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?

Hemoglobin 9.1 g/dL Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin. The other three laboratory values are within normal limits for the pregnant woman.

The nurse is collecting neurological data on a poststroke adult client. Which technique should the nurse perform to adequately check proprioception?

Hold the sides of the client's great toe, and while moving it, ask what position it is in.

The nurse is assisting in developing a teaching plan for a pregnant client diagnosed with diabetes mellitus. Which instruction is the priority for this client?

How to check for signs of hypoglycemia and the required treatment

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."

A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). Which response made by the nursing student is correct?

BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB."

The nurse is explaining about antigens and antibodies when the client asks where antibodies come from. The nurse should include which areas as the most appropriate response? Select all that apply.

Spleen Saliva Blood serum Lymph nodes Tears

The client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition?

Vomiting following cancer chemotherapy

The nurse is assisting with data collection for a parent and son during a well-child visit. The nurse determines the child is in the phallic stage of Sigmund Freud's theory of personality development if the parent makes which comment?

Yesterday my son asked me why he looked different from his sister."

The nurse is assisting in developing a plan of care for the client with immunodeficiency. The nurse should determine that which problem is a priority for the client?

Infection

The nurse is caring for a 45-year-old client. The client has 3 healthy children, all born via spontaneous vaginal birth. The client has been diagnosed with mild uterine prolapse and asks the nurse what she can do to prevent further prolapse. The nurse should include which instructions in the teaching plan? Select all that apply.

Lose weight. Eat a diet high in fiber. Perform Kegel exercises. Take a stool softener daily as needed.

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer.

The nurse is preparing to perform an abdominal examination. Which step should be taken first

inspection

The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia?

"I should expect that my urine output will decrease."

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply.

"The preembryonic period is the first 2 weeks of fetal development following conception. The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking zidovudine 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results indicate severe neutropenia. Which should the nurse next anticipate to be prescribed for the client?

Discontinuation of the medication

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

A man who is an inspector for the U.S. Postal Service

A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.

Edema Proteinuria Thrombocytopenia

The nurse is assisting in developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. Which nursing intervention should be included in the plan of care to manage this symptom?

Administer an antipyretic at bedtime.

The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse should include on the poster instructions to avoid which activities?

Being in the sun for prolonged periods during the daytime hours to ensure absorption of vitamin D

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition?

Bladder distention

The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food?

Cheese

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?

Drink a half a cup of orange juice before soccer practice.

A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help with morning sickness. Which should the nurse include in the instructions? Select all that apply.

Eat a low-fat diet. Stop or decrease smoking. Eat smaller, more frequent meals. Consume adequate fluid between meals.

A woman is 24 weeks pregnant. She had a previous stillborn neonate at 38 weeks' gestation and a pregnancy that ended at 34 weeks with the birth of a stillborn girl. She states she has a 4-year-old son and an 8-year-old daughter who live with her at home and were both born at 38 weeks. What is her gravidity and parity, using the five-digit system (GTPAL)?

G (5) T (0) P (4) A (0) L (2)

The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. The nurse should determine that which client population is at risk for developing this type of allergy?

Hairdressers

The nurse has reinforced discharge instructions to the mother of a child who is prescribed tetracycline to treat Rocky Mountain spotted fever (RMSF). Which statement by the mother indicates the best understanding regarding the administration of the medication?

I need to use a straw when I give the medication."

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs

Irregular, painless contractions

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date?

July 27, 2020

The nurse should include which instruction in a teaching plan for a client who has been diagnosed with peptic ulcer disease?

Learn to use stress reduction techniques.

The nurse should emphasize which statement when reinforcing instructions to a client about the use of indinavir?

Moisture can affect the potency of the medication.

Dapsone is prescribed for the client diagnosed with acquired immunodeficiency syndrome for the treatment of toxoplasmosis. The nurse should reinforce medication instructions and determine that the client understands the instructions if the client makes which statement?

Report a sore throat to the primary health care provider.

A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?

Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.

The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose?

Strengthen the pelvic floor in preparation for delivery.

The client is prescribed oral erythromycin. The nurse should reinforce which instruction regarding the administration of this medication?

Take on an empty stomach.

When checking a child's glossopharyngeal nerve function, the nurse should perform which data collection technique?

Test sense of sour or bitter taste on the posterior segment of the tongue. To test glossopharyngeal nerve function, the nurse would test the sense of sour or bitter taste on the posterior segment of the tongue. Option 1 is the data collection technique for checking the accessory nerve. Option 2 is the technique for checking the oculomotor nerve. Option 4 is the data collection technique for checking the facial nerve.

The nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate? The client will no longer have leg pain. The client will verbalize a reduction of pain. The client will report that an infection is likely to occur. The client will be able to identify measures to prevent infection.

The client will be able to identify measures to prevent infection.

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant. The nurse shares which tests are expected to be conducted during the first trimester? Select all that apply.

Urinalysis Rubella titer Complete blood count

The nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse should inform the students that which behavior is most unsafe?

Use of natural skin condoms Rationale: The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. Abstinence is the safest way to avoid HIV infection. The next most reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of the HIV virus as long as the condom is used properly and remains in place and intact.

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should schedule the medication so that each dose is taken at which time?

30 min bf meals.

The nurse is reinforcing instructions to a group of female clients about breast self-examination (BSE). When should the nurse instruct the pre-menopausal client to perform this examination?

One week after menstruation begins

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?

"At this age, the child is developing his or her own personality."

The nurse has reinforced instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client makes which statement?

"Begin voiding and then stop the stream, holding residual urine for an hour."

A client asks the nurse about metabolic syndrome and what it means. The teaching plan should include which characteristics that define metabolic syndrome? Select all that apply. Metabolic syndrome is a condition in which the client has metabolic factors that put the client at risk for developing diabetes type 2 and cardiovascular disease. Abdominal obesity with increased waist measurements (males greater than 40 inches, females greater than 35 inches) is part of the syndrome as is elevated blood pressure with systolic elevation greater than 130 mm Hg and diastolic greater than 85 mm Hg. Blood glucose levels are greater than 100 mg/dL, not 200 mg/dL. Triglyceride levels are part of the metabolic syndrome and levels greater than 150 mg/dL are part of the syndrome. High density lipoprotein (HDL) cholesterol is less than 40 mg/dL in males and 50 mg/dL in females in the syndrome. HDL is the good cholesterol and should be greater than 35 mg/dL.

Blood pressure is elevated with systolic values greater than 130 mm Hg and diastolic values greater than 85 mm Hg. The client has abdominal obesity with a waist greater than 40 inches in males and greater 35 inches in females.

The nurse is assessing the client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection?

Did you have chicken pox as a child?"

A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further teaching if the client states which? I will use latex condoms to prevent disease transmission. I will return to the clinic as requested for follow-up culture in 1 week. I will use an antibiotic prophylactically to prevent symptoms of Chlamydia. I will reduce the chance of reinfection by limiting the number of sexual partners.

I will use an antibiotic prophylactically to prevent symptoms of Chlamydia. Antibiotics are not taken prophylactically to prevent acquisition of urethritis from Chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners and by the use of condoms. In some instances, follow-up culture is requested in 4 to 7 days to confirm a cure.

The nurse employed in a neighborhood health care clinic notes that the primary health care provider has prescribed oseltamivir. The nurse should reinforce teaching the client specific home care measures after determining this medication was prescribed for which condition?

Influenza virus

A client who frequently experiences hearing loss due to built-up cerumen in the ears asks the nurse about ways to deal with the problem including irrigating the ears. Which information is correct for the nurse to include in the teaching plan? Select all that apply. Decrease ear cerumen by avoiding foods high in sodium content. Irrigate the ear canal with lukewarm tap water around 98° F. After a warm shower, cleanse ears canals gently with a cotton swab. The ear irrigation should be stopped if the client becomes dizzy or nauseous. Use an ear syringe to direct the flow of water straight into the ear during the irrigation. Instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation.

Irrigate the ear canal with lukewarm tap water around 98° F. The ear irrigation should be stopped if the client becomes dizzy or nauseous. Instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation.

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.

Oranges Broccoli Grapefruit Folic acid (folate) helps prevent neural tube birth defects; it is found in green, leafy vegetables; liver, beef, and fish; legumes; and grapefruit and oranges. Peanuts are high in protein and niacin. Milk is high in calcium and vitamin D. Egg yolks are high in vitamin A, iron, and cholesterol.

A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN makes which suggestion to the community nurse to direct the group most effectively?

Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem.

The nurse and a mother are discussing care of her child's iron deficiency anemia. The nurse should suggest including which foods in the child's diet that are highest in iron? Select all that apply. Spinach Apricots Raisins Egg whites Whole milk

Spinach Apricots Raisins Foods high in iron include egg yolk, liver, leafy green vegetables, Cream of Wheat, apricots, peaches, prunes and raisins, dry beans, crushed nuts, and whole-grain bread. Whole milk contains very little iron.

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction to the client? Avoid iron supplementation. Eat a diet high in vitamin B12. Take actions to prevent dumping syndrome.

Take actions to prevent dumping syndrome.

A parent calls the clinic nurse to schedule an appointment for her child's diphtheria, tetanus, and pertussis vaccination. The parent tells the nurse that her child had a swelling at the injection site and low-grade fever after the last diphtheria, tetanus, and pertussis (DTaP) vaccination. Which instructions should the nurse give to the parent to lessen this type of reaction to the upcoming vaccination?

To administer an appropriate dose of Tylenol 45 minutes before the appointment