Healthpromotion

Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? feelings of relief excitement loss of control numbness of the legs

loss of control Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts.

Which client is at greatest risk for coronary artery disease? a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago a 43-year-old male with a family history of coronary artery disease (CAD) and cholesterol level of 158 (8.8 mmol/L) a 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L)

a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L) The woman who is 65 years old, overweight, and has an elevated LDL is at greatest risk. Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.

A nurse is caring for a client who is scheduled for amniocentesis. What will the nurse teach the client about this procedure? She may experience mild contractions after the procedure. Fetal monitoring will be done for 45 minutes prior to the procedure. An overnight stay in the hospital is needed. She needs to empty her bladder prior to the procedure.

She needs to empty her bladder prior to the procedure. While preparing a client for an amniocentesis, the woman should empty her bladder to avoid the risk of bladder puncture. The fetus will be monitored for 20 minutes prior to the procedure to evaluate fetal well-being and obtain a baseline to compare after the procedure. If the mother is Rh-negative, RhoGAM will be administered after the procedure to prevent potential sensitization to fetal blood. The fetal heart rate will be monitored continuously and the mother's vital signs every 15 minutes for an hour after the procedure. The nurse will assess the puncture site for bleeding. After recovery, the mother will go home to rest with instructions to report any bleeding or contractions. The mother should not have any contractions after the procedure.

Client is a 2-year-old who presented to the emergency department after reportedly choking on a grape during lunch. Guardian reports the toddler was not able to dislodge food naturally and was choking but not making noise. Back blows were performed causing food to dislodge and child was able to breathe becoming asymptomatic. Complete the following sentence by choosing from the lists of options. The client is at highest risk for developing.........and should be monitored for.........

asthma, signs of infection. The nurse will need to monitor for signs of infection due to client's increase risk related to aspiration of food into airway, most specifically aspiration pneumonia. Foreign body aspiration places a person, especially children, at high risk for aspiration pneumonia. This is due to any foreign substance aspirated into the lungs causing infection. The nurse will need to monitor for infection due to client being at high risk for infection, most specifically aspiration pneumonia. A pneumothorax occurs when a lung deflates. This is typically caused by traumatic injury and is not associated with foreign body aspiration. Asthma is a respiratory disorder in which the airways constrict and is unrelated to foreign body aspiration. Wheezing upon exhaling is a manifestation of asthma. This client is not experiencing asthma. Sudden onset of chest pain is a manifestation of a pneumothorax and is unrelated to foreign body aspiration.

The nurse is determining whether a client is able to manage care at home. A home care referral has been placed. What is the priority assessment by the nurse to determine the client's ability to manage care at home? functional age chronologic age developmental stage all risk score

functional age

The nurse is assessing a 2-year-old child's development. What assessment finding would warrant further investigation by the nurse? constantly stating "no" to instructions requesting the same bedtime story every night having a vocabulary of 100 words building a small tower with 5 blocks

having a vocabulary of 100 words The favorite word of a two-year-old is "no." It is a way to exert their independence and test limits. Two-year-olds like repetition because it provides security, so reading the same book every night provides stability and comfort. They can build a block tower of 4-5 blocks. A two-year-old should have a vocabulary of 200 words, so a smaller vocabulary could indicate a development delay.

The nurse is caring for a postpartum client with an episiotomy. The nurse assesses the client closely for what complication that the client is at greatest risk of developing? blood loss urinary incontinence infection dyspareunia

infection

A client who is 6 months postpartum asks the nurse about an effective method of birth control. What is the nurse's most appropriate response? "Breastfeeding alters your hormones and provides adequate protection against pregnancy." "Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding." "Combined oral contraceptive pills are a good option for breastfeeding mothers." "Spermicidal foam protects against pregnancy as effectively as other methods."

"Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding."

A 22-year-old primigravida approaches the nurse during the prenatal clinic and states that her partner is saying hurtful comments about her weight gain. What is the most appropriate response from the nurse? "You sound offended, but it is important that you gain a certain amount of weight during your pregnancy." "How much weight have you gained?" "What do you think of your changing shape?" "Tell me how you are feeling about your partner's comments."

"Tell me how you are feeling about your partner's comments."

A nurse has been providing care to a client in labor for the past 9 hours. The partner remains at the bedside while the laboring client is sleeping with the epidural block in situ. Which is the most appropriate nursing action? Encourage the partner to take a break for 1 hour. Instruct the partner to contact another support person take their place because the partner is exhausted. Offer to remain with the client while the partner takes a short break. Suggest that the partner goes home to sleep for a few hours.

Offer to remain with the client while the partner takes a short break.

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse's priority intervention? Position the client in the lithotomy position. Place the client on her left side and apply oxygen. Call the client's provider. Slow down the client's I.V. rate.

Place the client on her left side and apply oxygen.

When instructing a client about the proper use of condoms for pregnancy prevention, the nurse should include which instructions to ensure maximum effectiveness? Place the condom over the erect penis before coitus. Withdraw the condom after coitus when the penis is flaccid. Ensure that the condom is pulled tightly over the tip of the penis before coitus. Obtain a prescription for a condom with nonoxynol 9.

Place the condom over the erect penis before coitus.

What recommendation should the nurse give a family about appropriate beverages for children? Give children whole milk until 5 years of age. It is better to give your child bottled water rather than tap water. Offering sports drinks is the ideal way to provide hydration during physical activity. Sugary drinks, including juice, should be avoided.

Sugary drinks, including juice, should be avoided.

A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis? Wash the perineum with warm water and soap, cleaning from front to back. Treat fungal infections such as athlete's foot immediately. Have a pneumonia immunization to prevent streptococcal infection. Treat skin lesions with antibiotics, and cover any open lesions.

Wash the perineum with warm water and soap, cleaning from front to back.

A nurse observes two 2-year-old children playing. The nurse documents what form of play as normal for this age group? riding tricycles near each other playing a game of catch with a ball pretending to "race" toy cars with each other digging side-by-side in a sandbox

digging side-by-side in a sandbox Two-year-old children exhibit parallel play. They engage in similar activity, side by side. Two-year-old children have very short attention spans, so they change toys easily when playing. Taking turns in games does not occur until age 3 years, and playing catch is a "take turns" activity. Pretending to "race" toy cars is more suggestive of cooperative play, in which the children work together. Cooperative play is more typical of children 4 to 5 years of age. Riding tricycles near each other represents independent play. While the children are performing the same activity, they do not maintain the constant proximity ("side-by-side") exhibited in the parallel play that is common among 2-year-olds.

The nurse returns the newborn to the new mother after obtaining assessment data and performing newborn interventions. The nurse recognizes the best evidence of positive bonding when the mother: engages in direct eye contact with the infant. takes multiple photos of the infant to share on social media. asks the nurse many questions about caring for the infant. gently taps the baby's back after feeding.

engages in direct eye contact with the infant.

new nurse asks the charge nurse why the client with body dysmorphic disorder is always looking at their nose in the mirror. Which of the following would be an appropriate response? "Clients with body dysmorphic disorder are encouraged to face their fears by focusing on their appearance." "Clients with body dysmorphic disorder use repetitive compulsions to reduce their anxiety." "Clients with body dysmorphic disorder are preoccupied with perceived defects in their appearance." "Clients with body dysmorphic disorder focus on their appearance to have a feeling of control."

"Clients with body dysmorphic disorder are preoccupied with perceived defects in their appearance." Clients with body dysmorphic disorder have an exaggerated perception of a flaw of their body. Due to their anxiety, they will be preoccupied about their distorted appearance (at least 1 hour a day). They will perform repetitive behaviors focusing on their body flaw, which will cause more anxiety and more obsessiveness. Focus on the appearance does not offer a sense of control, nor does it exert control over any fears.

A parent brings a child to the clinic with symptoms of weight loss, paleness, fatigue, and not growing. What question about the child's environment should the nurse ask the parent based on these symptoms? "How old is the house that you live in?" "Do you have pets in your home?" "Are you a single parent?" "Do you live near a hydroelectric facility?"

"How old is the house that you live in?" The nurse should suspect lead poisoning in this situation. Many of the symptoms are the same as other illnesses, but the key is living in the older home. Lead poisoning occurs through older lead pipes and drinking water from those pipes. Lead is also found in the dirt in areas surrounding homes where lead pipes and lead paint have been used. The symptoms of lead poisoning include weight loss, being tired all the time, difficulty concentrating, and abdominal pain. The concern for living near a hydroelectric facility would be methylmercury poisoning. The symptoms of this would include lack of coordination, speech impairments and muscle weakness. The type of pets in the home could indicate symptoms of a disease such as asthma. The concern for being a single parent would be one of financial need and not being able to purchase nutritious foods for the child.

The home care nurse is conducting a follow-up visit to a client who was recently discharged to home with intermittent total parental nutrition (TPN) therapy. What statement by the client leads the nurse to determine that additional teaching is needed? "I will change the I.V. administration tubing every week." "If the catheter dressing becomes loose, I will change the dressing." "I will wash my hands prior to initiating my nightly TPN." "I will avoid catheter contact with lint-producing materials."

"I will change the I.V. administration tubing every week." Additional teaching is needed if the client states, "I will change the I.V. administration tubing every week." The tubing should be changed every 24 hours to decrease the risk of infection. The client should change the catheter dressing when it becomes loose and wash the hands prior to initiating or discontinuing the TPN to decrease the risk of infection. The client should also avoid catheter contact with lint-producing materials to prevent a local reaction or irritation.

The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship? "You have a lot to live for." "I'm sorry this is happening to you." "Would you like me to call your parents?" "The voices are not real."

"I'm sorry this is happening to you." Demonstrating empathy is an effective means of beginning an effective therapeutic relationship. Challenging the client's beliefs or thoughts is not the most effective in establishing a trusting relationship. Determining what supports are needed is done after an initial assessment.

A child age 4, begins to use curse words. Concerned about this behavior, the parents ask the nurse how to discourage it. Which advice should the nurse offer? "Just ignore it. Children grow out of it." "Tell the child it isn't acceptable and they will be disciplined if it continues." "Tell the child that good little children don't use curse words." "Tell the child that the behavior makes you angry."

"Just ignore it. Children grow out of it."

A client who recently had a colostomy expresses concerns about the sexual relationship with the client's spouse. Which statement made by the nurse is appropriate? Let me speak with your spouse. Your spouse might be okay with it." "We have a psychiatrist available for sexual dysfunction therapy." "Give your spouse time to get over it." "I can refer you to a support group so that you can speak with others with similar problems."

"I can refer you to a support group so that you can speak with others with similar problems." Having this client speak with someone who has had a similar surgery and concerns would be beneficial. Discussing the client's concerns with the spouse does not address the client's needs. The client is coping normally and does not need professional help. In fact, the client may feel that the nurse violated confidentiality

A client with newly diagnosed chronic obstructive pulmonary disease (COPD) presents to the clinic for a routine examination. The nurse teaches the client strategies for preventing airway irritation and infection. Which statement by the client best indicates that teaching was successful? "I only need to avoid crowds during flu season." "I'm glad I only need to get the flu vaccine to prevent respiratory illnesses." "I should use products with aerosol sprays." "I should avoid using powders."

"I should avoid using powders."

The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response? "The fetal heart rate dropped during the contractions, so we may need to induce you." "I'm sorry, your provider will have to inform you of the results of the test." "The fetal heart rate went up twice during the test, so your fetus is doing well." "It is too early to tell, we will need to repeat the test in 2 weeks."

"The fetal heart rate went up twice during the test, so your fetus is doing well."