semester 3 EAQs

The plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. How does the nurse determine whether the desired effect of therapy has been achieved?

Mobility increases

The parents of a school-age child tell the nurse that their child is tall, broad, and very active in sports, so they are planning to enroll the child for strenuous competitive athletics. What is the best response from the nurse?

The child is not ready for strenuous activities.

A nursing instructor asks a student to describe the moral developmental theory. Which statement made by the student indicates a need for further teaching?

The fifth stage defines 'right' by the decision of conscience in accordance with self-chosen ethical principles."

A nursing instructor asks a nursing student about the level "conventional reasoning" in Lawrence Kohlberg's theory of moral development. Which statements made by the student indicate the need of further teaching? Select all that apply.

"A child recognizes that there is more than one correct view. "A child's response to a moral dilemma is in terms of absolute obedience to authority and rules." "An individual follows societal law but recognizes the possibility of changing the law to improve society."

A client with a benign ovarian tumor undergoes laparoscopic surgery. What should the nurse include in the postoperative teaching?

"Expect shoulder pain for 12 to 24 hours."

After assessing a newborn infant, the nurse finds that infant has a heart rate of 90 beats/min, irregular respirations with a weak cry, limp extremities, sneezing reflex, and a completely pink body. What would be the Apgar score of the child? Record your answer using a whole number. ______

6 The infant has a heart rate of 90 beats/min, which is given a score of 1. The infant also has irregular respiration with a weak cry, which is scored as 1. The infant has limp extremities, which receives a score of 0. The infant has the sneezing reflex, which is given a score of 2. The infant has a completely pink body, which is also given a score of 2. Therefore, the total Apgar score of the infant is 1 + 1 + 0 + 2 + 2 = 6.

What is the similarity between stages 5 and 6 of Kohlberg's theory?

Both stages are associated with postconventional reasoning.

Which priority teaching point should the nurse include when educating parents how to facilitate the developmental task of trust for their newborn?

Breastfeeding the newborn on demand

What is the priority nursing intervention before a client undergoes amniocentesis?

Ensuring that informed consent has been obtained from the client

A nurse is teaching a group of women about the side effects of different types of contraceptives. What common side effect associated with the use of an intrauterine device (IUD) should the nurse discuss during the teaching session?

Excessive menstrual flow

A 26-year-old woman whose sister recently had a lumpectomy for breast cancer calls the local women's health center for an appointment for a mammogram. What guidance should the nurse provide the client in preparation for the test?

During the procedure, each breast will be compressed firmly between two plates.

According to Kohlberg's theory, which stage comes before the society-maintaining orientation stage?

Good boy-nice girl orientation

A nurse is interviewing a female client with a tentative diagnosis of cystitis pending laboratory results. The nurse anticipates that the causative agent of the cystitis is Escherichia coli. Why does the nurse anticipate this microorganism?

It inhabits the intestinal tract

Which is a common attribute that the nurse assesses in an "easy" child?

Predictable habits

Which statement is true regarding the physical development of a preschooler?

Preschoolers grow 6.2 to 7.5 cm per year

A nurse is obtaining a health history from a client with newly diagnosed cervical cancer. Which aspect of the client's life is most important for the nurse to explore at this time?

Support system

A client with osteoporosis has been receiving dietary information from the nurse. Which food selection by the client indicates that the nurse's dietary instruction was effective?

Turnip greens

Which teaching points should the nurse include when educating the parents of a school-age client to decrease the risk for burn injury? Select all that apply.

Using a low heat setting when cooking instructing on the stop, drop, and roll technique Making sure smoke detectors are installed in the home

The nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? Select all that apply.

carrots Cantaloupes

A client underwent a mastectomy 24 hours ago. Which information is most important for the nurse to include in the plan of care?

he hand and elbow of the affected arm will be elevated above the shoulder.

During a physical examination, the nurse finds that a 3-year-old child has markedly fewer teeth than expected for that age. Which foods should be included in the child's diet to promote tooth formation? Select all that apply.

skim milk kale

According to Freud's theory, in what order do the stages of child development occur?

1. Oral 2.Anal 3.Oedipal 4.Latency 5.Genital

What important instruction should a nurse include when teaching about the correct use of a female condom?

"Remove the condom before standing up."

A nurse is teaching breast-feeding to a newly delivered client. Which statement by the client indicates the need for further instruction?

"I need to wash my breasts with soapy water before I breast-feed."

A female client who is receiving intravenous antibiotic therapy at home for treatment of toxic shock syndrome is visited by a home health nurse. What statement indicates to the nurse that the client understands the teaching regarding future care?

"I will call the clinic if I get a rash."

A nurse is discussing sexuality with a teenage female who has cystic fibrosis. Which statement best reflects the teenager's understanding of healthy sexuality?

"I won't have sex unless I use a condom."

The nurse is teaching an adolescent about the different methods of contraception. Which statement made by the adolescent indicates a need for further teaching?

A diaphragm is a soft rubber dome and requires nothing else.

A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor that both she and her husband have noticed. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection does the nurse suspect?

Bacterial vaginosis

Which topic should the nurse include when teaching an expectant couple and their existing children about meeting the psychosocial development of the newborn?

Family involvement as a means of nurturing

During a follow-up visit, the nurse finds that the adolescent uses artificial tanning methods and has phototoxic reactions on the skin. What is the nurse's best response?

You should wear goggles if you insist on using the tanning booth.

During the routine assessment of an infant, the nurse finds that the child demonstrates a certain neurologic reflex for the first time. When the infant is suspended in a horizontal prone position, the head is raised and legs and spine are extended. What is most likely to be the infant's age?

7 months An infant demonstrates the Landau reflex when, on being suspended in a horizontal prone position, the head is raised and legs and spine are extended. This reflex appears at 6 to 8 months and lasts until 12 to 24 months. So, the infant in this scenario is most likely to be 7 months old as she is demonstrating this reflex for the first time. The Landau reflex is not seen at ages 2 or 3 months. Instead, labyrinth righting appears at 2 months, and neck righting appears at 3 months. The Landau reflex lasts until 12 to 24 months. So, the age of the infant is not likely to be 36 months.

The nurse teaches a mother about the dietary measures to be followed for her 5-month-old infant. During the follow-up visit, the nurse finds that the child has indigestion. Which action by the mother is responsible for this situation?

Feeding properly mashed sweet potatoes to the child

A nurse is planning care for a client who gave birth to a preterm male infant. Which response does the nurse anticipate that this mother may experience?

Feelings of failure and loss of control

Which aspects of the "self" do children assess while forming their self-esteem? Select all that apply.

Moral worth Competence Sense of control Worthiness of love

After completing the physical examination of a 6-month-old infant, the nurse compares the infant's height, weight, and head circumference with the previous findings. What does the nurse infer from these findings?

The infant is developing normally The infant has normal growth and development. Infants generally gain 150 to 210 g of weight per week for the first 6 months and at least double their birth weight by 6 months of age. Infants grow 1 inch (2.5 cm) monthly for the first 6 months. Head circumference in infants increases by 1.5 cm per month for 6 months. Therefore, the body weight, height, and head circumference of 6.08 kg, 25.5 inches, and 44 cm at 6 months of age are normal findings. The infant does not have abnormal growth of height; therefore he or she may not develop gigantism. The infant does not have abnormal head circumference indicating megacephaly. The infant does not have abnormal body weight indicating a risk for childhood obesity.

A couple interested in delaying the start of a family discuss the various methods of family planning. Together they decide to use the basal body temperature method. The nurse explains that the fertile period surrounding ovulation lasts from when to when?

72 hours before to 24 hours after ovulation

According to Erikson's theory of psychosocial development, which should the nurse include in the plan of care for a young adult client who is hospitalized?

The importance of having support from the client's significant other.

During her first visit to the prenatal clinic a client is found to be obese. During the ensuing 5 months, the client has been unsuccessful in adhering to her nutritional plan. Which finding indicates to the nurse that the client has been successful during the sixth month?

Weight gain of 2 lb (0.91 kg)

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, what information about the client should the nurse obtain?

Whether an earlier tuberculin test's result was positive

What is the most important information for the nurse to teach to a client who has had a total simple mastectomy before she leaves the hospital?

Why self-examination of the remaining breast is important

Which parental action would require the nurse to provide additional education related to the toddler-age client's achievement of autonomy versus shame and doubt?

Yelling at the child for having a bathroom-related accident in the waiting room

A multipara who is admitted to the hospital for repair of a rectocele and cystocele asks a nurse why these problems happened to her. How should the nurse respond?

"You have relaxation of the muscles in your lower pelvis."

A nurse practitioner prescribes doxycycline for a sexually active woman with a history of mucopurulent discharge and bleeding associated with cervical dysplasia, dysuria, and dyspareunia. With which sexually transmitted infection are these clinical findings and medication therapy commonly associated?

Chlamydial infection

A nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. Which changes does the nurse explain result from the melanocyte-stimulating hormone? Select all that apply.

Chloasma Linea nigra

During labor an internal fetal monitor is applied. Which fetal heart rate (FHR) should most concern the nurse?

One that returns to baseline after a contraction ends A return of the FHR to baseline after a contraction ends is called a late deceleration; it begins after the contraction has started, the lowest point of the deceleration occurs after the peak of the contraction, and the deceleration usually does not return to baseline until after the contraction ends (late recovery). Late decelerations, which are caused by uteroplacental insufficiency, are a sign of a compromised fetus. The FHR does not always drop with a contraction. Beat-to-beat variability indicates a fetus with a healthy nervous system and does not warrant concern. A decrease in fetal heart rate to 110 beats/min during a contraction, known as an early deceleration, is the result of fetal head compression during a contraction; the FHR returns to baseline at the same time that the contraction ends.

A school-age child often steals money from home to buy chocolate. Upon being confronted by the parents, the child lies about stealing. The parents are worried that such behavior will steer the child toward criminal activities later in life. What is the best response from the nurse?

Use admonition and ask the child to return the stolen money."

The nurse is teaching the mother of 24-month-old child effective ways of cleaning the toddler's teeth. Which actions facilitate access to the child's mouth and help stabilize the child's head for comfort? Select all that apply.

Using one hand to hold the child's chin and the other to brush the teeth Sitting on a couch or bed with the child's head resting in the mother's lap Sitting on the floor or a stool with the child's head resting between her thighs