306 Exam 3/Final Pearson Questions

Which client would benefit from a hearing​ aid? A. A client with stenosis in the ear canal B. A client with Meniere's disease C. A client with bacterial meningitis D. A client taking ototoxic drugs

A A client with a conductive hearing loss such as stenosis in the ear canal will benefit from amplification by a hearing aid.​ Ménière disease, ototoxic​ drugs, and bacterial meningitis are sensorineural kinds of loss for which hearing aids will not be as helpful.

The nurse is caring for a client who can bear weight but has a weak limb. Which assistive device is the most appropriate for this client? A. Cane B. Walker C. Crutches D. Wheelchair

A Assistive devices are used to provide balance and support and increase confidence with independent ambulation. They also reduce pressure on an injured​ limb, prevent further​ injury, and promote healing. Canes are used by clients who can bear weight but are unsteady or have a weak limb. When using a​ walker, the arms support the majority of the body weight. For​ crutches, upper body and trunk strength is needed. A wheelchair will not assist with ambulation.

The nurse is encouraging socialization for a client with hearing loss. Which activity would be best for this​ client? A. Chess game B. Board game C. Group discussions D. Card games

A Chess is an activity that does not require hearing for participation. Board​ games, card​ games, and discussions require more social interaction and hearing ability.

A client with sudden sensorineural hearing loss comes to the clinic. Which medication should the nurse expect to be​ prescribed? A. Alkylating agent B. Aminoglycoside C. Corticosteroid D. Loop diuretic

C Corticosteroids are used to reduce inflammation and can help with temporary hearing loss. Medications such as​ aminoglycosides, alkylating​ agents, and loop diuretics can all cause hearing impairment.

The nurse is caring for a client with visual impairment. The nurse understands that which comorbidity is associated with visual deficits? Select all that apply. A. Dizziness B. Convergence C. Stroke D. Hypertension E. Diabetes

C, D, E The comorbidities associated with visual deficits include​ diabetes, hypertension, and stroke. Dizziness is associated with hearing loss. Convergence is the ability of the eyes to turn inward together and is a normal finding.

A client has not been told about dying but anticipates that death is near. In which state of awareness is this client? A. Suspected B. Mutual pretense C. Closed D. Open

A In suspected​ awareness, no one directly tells the client about the​ condition, but the client begins to suspect that death is near. In open​ awareness, the​ client, family, and healthcare team know about the​ client's impending death and discuss it openly. In closed​ awareness, the client is unaware of impending​ death, even though the healthcare team and family are aware. In mutual pretense​ awareness, the​ client, family, and healthcare team all know that the​ client's condition is​ terminal, but no one discusses it.

A pregnant client asks why she is being screened for certain diseases such as toxoplasmosis and syphilis. Which is the most accurate response from the​ nurse? A. These diseases can impact your health and the health of a developing fetus B. These diseases do not impact your health but can affect a developing fetus C. These diseases can impact the health of a developing fetus D. These diseases can impact your health and need to be cured

A In utero infections with TORCH pathogens​ (toxoplasmosis, rubella,​ cytomegalovirus, syphilis,​ herpes) can impact the health of the woman and a developing​ fetus, specifically increasing the risk of hearing loss for the infant.

A nurse is performing an oral health nursing assessment on an adult client/ The nurse notes the presence of pyorrhea. Which does this finding indicate? A. The presence of glossitis B. The presence of periodontal disease C. The presence of stomatitis D. The presence of fungal disease

B Pyorrhea is the presence of pus at the gums when pressed. This is a manifestation of periodontal​ disease, not fungal disease. Stomatitis is the inflammation of the​ mouth, whereas glossitis is the inflammation of the tongue.

The nurse is reviewing documentation on a client at risk for developing a pressure injury. Which note in the documentation should indicate to the nurse that the plan of care has been followed​ correctly? A. Client refusing meals. Nutritional consult prescribed B. Client turned every 4 hours C. Client ate all of lunch. Given a nutritional supplement D. Client comfort and pain level assessed daily

A Nutritional consults should be prescribed for clients with inadequate nutritional intake. Clients should be turned every 2 hours. Client comfort and pain should be assessed more often than daily. Nutritional supplements should be given to clients who eat​ 50% or less of their meals.

The nurse is reviewing the chart of a client diagnosed with paronychia. Which assessment finding should the nurse​ anticipate? A. Infection around the fingernail B. Superficial skin infection in children C. Fungal oral mucosal infection D. Infection of the hair follicles

A Paronychia is a soft tissue infection around the fingernail. Folliculitis is an infection of the hair follicles. A fungal oral mucosal infection is known as candidiasis. Impetigo is a superficial skin infection in children.

A client asks what effect nutrition has on skin integrity. Which response should the nurse make that explains the relationship of nutrition to pressure injury​ development? A. Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure injuries B. Increased dietary intake of protein can cause pressure injuries C. Increased dietary intake of carbohydrates and minerals can cause pressure injuries D. Poor dietary intake of primary fatty foods can increase the risk of pressure injuries

A Poor dietary intake of​ kilocalories, protein, and iron has been associated with the development of pressure injuries. Fatty foods may offer kilocalories to the client but are not an adequate source of nutrition to prevent pressure injuries. Increased intake of protein will not cause pressure injuries to develop.

The nurse is planning care for client with hearing loss. Which outcome is of highest priority for the​ client? A. The client will remain free from injury B. The client will remain involved in the community C. The client will find a method of communication D. The client will have increased feelings of self-worth

A Safety is the highest priority for a client with hearing loss.​ Communication, socialization, and​ self-worth are not as important as safety.

The nurse performing a home visit for an older adult client determines the client would benefit from teaching about the promotion of skin integrity. Which assessment finding indicates the need for further​ teaching? A. The client uses a body spray perfume B. The client applies moisturizer after bathing C. The client showers four times a week D. The client washes their hands with soap and running water before eating

A The client using a body spray perfume is at risk of impaired skin integrity. Perfumes contain​ alcohol, which dries the skin. Showering four times a​ week, applying a moisturizer after​ bathing, or washing hands with soap and running water prior to eating do not place the client at risk for impaired skin integrity.

The nurse is reviewing the chart of a client who has developed keloids as a result of multiple surgeries. Which assessment finding should the nurse​ anticipate? A. Elevated, irregular, darkened area B. Flat, irregular area of connective tissue C. Rough, thickened, hardened area of epidermis D. Wearing away of the superficial epidermis

A The nurse can expect to find an​ irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. A scar is a​ flat, irregular area of connective tissue left after a lesion or wound has healed. A wearing away of the superficial epidermis causes a​ moist, shallow depression known as erosion. Lichenification is characterized by a​ rough, thickened, hardened area of epidermis.

The nurse observes a​ mother, father, and toddler coming in to visit a client. The toddler has a runny nose and is sniffling. Which safety concern should the nurse address before letting the family visit the​ client? A. Risk of infection B. Falling C. Noise D. Overstimulation

A The toddler who has a runny nose and is sniffling is showing signs of a viral or bacterial infection. The nurse must gently and firmly address this issue by following agency policy and offering the family members masks to wear in the room or informing the parents that the sick child cannot visit at this time.

Which signs in a child would lead the nurse to recommend a hearing​ evaluation? Select all that​ apply. A. Difficulty understanding speech when background noise is present B. Language delays C. Behavior issues D. Listening to the television at a higher volume E. Startling to loud sounds

A, B Signs of hearing loss in children include speech and language delays and difficulty understanding speech when background noise is present. Startling to loud​ sounds, attention or behavior​ problems, and listening to television or radio at a higher volume are not signs of hearing loss in children.

The nurse is reviewing a​ client's chart who presents to the clinic with report of a​ "skin rash." Which descriptive characteristic indicates a specific skin disorder that the nurse may​ consider? Select all that​ apply. A. Macule B. Vesicle C. Wheal D. Exudate E. Pruritis

A, B, C Characteristics of skin disorders include​ macules, wheals, and vesicles. Exudate is fluid drainage from a wound. Pruritus is itching of the skin.

The nurse is conducting an assessment with the parent of a​ 6-year-old child with cerebral palsy. When focusing on the​ child's safety, which is an appropriate question to ask the​ parent? Select all that​ apply. A. Are your child's toys developmentally appropriate? B. Does your child play on a playground with soft surfaces C. Are the restraints in your motor vehicle adapted for your child D. Does anyone in the home smoke

A, B, C Questions that focus on the​ child's safety include​ "Are the restraints in your motor vehicle adapted for your​ child?" "Does your child play on a playground with soft​ surfaces?" and​ "Are your​ child's toys developmentally​ appropriate?" The questions​ "Does anyone in the home​ smoke?" and​ "Is your child current with their​ vaccinations?" are questions that focus on strategies to prevent disease.

Question content area top Part 1 The charge nurse receives report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure​ injuries? Select all that​ apply. A. Client who is 92 years-old B. Client on bedrest C. Client with type 1 diabetes mellitus D. Client with a history of anorexia nervosa E. Client admitted to an acute care unit

A, B, C, D A client on bedrest is​ immobile, which increases the risk for developing pressure injuries. An older adult client is at risk because of the loss of lean body​ mass, epidermal​ thinning, decreased skin​ elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissues. A client with a history of anorexia nervosa is at risk because of inadequate​ nutrition, which leads to weight​ loss, muscle​ atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not the only reason someone would be at risk for developing a pressure injury.

The nurse is preparing to perform an assessment on a client. Which factor should the nurse include in the integumentary​ assessment? Select all that​ apply. A. Turgor B. Temperature C. Nails D. Texture E. Sensation

A, B, C, D An integumentary assessment includes the​ nails, skin​ turgor, texture, and temperature. Sensation is included in a neurological examination.

A client with poor nutritional intake is at high risk for developing pressure injuries. Which device should the nurse identify as appropriate for this​ client? Select all that​ apply. A. Foam wedges and pillows B. Gel flotation pads C. Memory foam chair pad while client is in chair D. Static low-air-loss bed E. Rolled blankets to protect heels

A, B, C, D Gel flotation pads can be used to protect bony prominences and are filled with a substance similar to fat. A static​ low-air-loss bed is made up of many​ air-filled cushions that can be reduced under bony prominences and inflated to provide support in other areas. Foam wedges and blocks can be used to prevent​ bone-on-bone contact and support positioning. Memory foam chair pads distribute weight more evenly over the surface of the seat and can mold to the body. Foam​ blocks, not rolled​ blankets, are used to protect heels from shearing and limit pressure.

The nurse is caring for a​ 9-year-old client who was injured while riding a bicycle down a steep hill while the​ client's mother was at work. Which underlying safety issue should the nurse​ address? Select all that​ apply. A. Review the importance of wearing protective gear, such as helmets and long sleeved clothing while riding bicycles B. Investigate possible emotional triggers for risky behavior, such as choosing to bike down a steep hill C. Review the physical and emotional needs of latchkey children with the mother D. Address whether a peer group is encouraging risky behavior E. determine the nutritional status of the child

A, B, C, D The nurse should review bicycle​ safety, peer​ involvement, latchkey​ children's emotional​ needs, and reasons for risky behavior. Bicycle safety is important given the history of a serious accident.​ School-age children are often​ "latchkey" children, old enough to stay alone while a mother is at​ work, but they have physical and emotional needs that need to be addressed carefully.​ Otherwise, they may find a negative peer group or engage in risky behaviors to act out. The nutritional status of the child is not relevant to risk for injury.

The nurse is caring for a client admitted with a pressure injury. Which data should the nurse document when assessing the pressure​ injury? Select all that​ apply. A. Integrity of the surrounding tissue B. Color of the wound bed C. Stage of the ulcer D. Home management of the pressure injury E. Signs of infection

A, B, C, E Documenting the stage of the pressure​ injury, color of the wound​ bed, integrity of the surrounding​ tissue, and signs of infection are of utmost importance. Assessment of home management does not need to be documented.

The nurse is assessing a client with hearing loss. Which assessment should the nurse include in the physical​ examination? Select all that​ apply. A. Cranial nerve function B. Speech C. Hearing D. Exercise routine E. Balance

A, B, C, E The nurse should assess the speech of a client with hearing loss. A client with hearing loss may have impaired balance or cranial nerve​ dysfunction, and the nurse must assess for these. Assessing a​ client's exercise routine is not specific to the physical assessment of a client with hearing loss.

The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify that this dressing is used? Select all that apply. A. Stage 3 B. Stage 4 without eschar C. Stage 1 D. Stage 2 E. Deep tissue injury

A, B, D Alginate dressing should be used for stages​ 2, 3, and 4 without eschar pressure injuries but is not suitable for a deep tissue injury. An alginate dressing is not used for stage 1 pressure injuries.

While completing a health​ history, the nurse becomes concerned that a pregnant client is at risk for having a miscarriage. Which information in the​ client's history is causing this​ concern? Select all that​ apply. A. The client's husband uses marijuana in the home B. The client drinks alcoholic beverages several times a week C. The client has two other children D. The client smokes one pack of cigarettes per day E. The client ingests fresh fruits and whole grain products

A, B, D Reasons for miscarriage include lifestyle and behavioral​ factors, such as the use of​ alcohol, illegal​ drugs, and tobacco. Having two other children does not increase the risk for miscarriage. Ingesting fresh fruits and​ whole-grain products is a positive health choice and would not adversely affect the developing fetus.

The nurse is caring for a client with incontinence of urine and sudden onset of watery diarrhea. Which action should be included in the plan of care to maintain skin​ integrity? Select all that​ apply. A. Clean skin immediately at the time of soiling and routinely B. Apply a moisturizing barrier cream to the skin at greatest risk of breakdown C. Increase humidity in the room and limit exposure to cold D. Massage bony prominences at least twice daily to promote circulation E. Apply a moisturizing barrier cream to the skin at greatest risk of breakdown

A, B, D To maintain skin integrity of a client with incontinence of urine and​ stool, the nurse should assess skin systematically at least once a​ day, clean skin immediately upon soiling and​ routinely, increase the humidity in the room and limit exposure to​ cold, and apply a barrier cream to the skin at the greatest risk of breakdown. Bony prominences should not be massaged.

A client is being assessed for hearing loss. Which test would be used for the assessment of the hearing​ function? Select all that​ apply. A. Phalen's test B. Webers test C. Romberg test D. Rinne test E. Whisper test

B, D, E Assessment screenings for hearing impairment include the whisper​ test, otoscope​ examination, tympanogram, and use of a tuning fork to perform the Rinne and Weber tests. The Romberg test is used to assess balance and​ Phalen's test is used to assess carpel tunnel syndrome.

A client is suspected of having a deep tissue injury. Which intervention should the nurse include in the plan of​ care? Select all that​ apply. A. Consideration of appropriate support surfaces and other measures to remove all pressure B. Application of a nonadhesive protective dressing C. Wet-to-damp dressing changes twice daily D. Application of a moisturizing barrier cream E. Debridement of wound bed and edges

A, B, D To treat a client with a suspected deep tissue​ injury, the nurse should apply a moisturizing barrier​ cream, a nonadhesive protective​ dressing, and consider support surfaces that will remove all pressure from the area. Debridement of wound bed and edges and​ wet-to-damp dressing changes are not appropriate for deep tissue injuries.

The nurse is preparing a client scheduled for a skin biopsy. The client asks how this will be done. Which procedure should the nurse​ include? Select all that​ apply. A. Punch B. Shaving C. Culture D. Incision E. Excision

A, B, D, E A skin biopsy can be obtained by a​ punch, incision,​ excision, or shaving. Cultures are used to identify infections obtained from tissue​ samples, wounds,​ drainage, lesions, or serum.

Which intervention should the nurse implement as a standard safety measure for adult​ clients? Select all that​ apply. A. Alerting the nurse to changes in pain or physical condition B. Encouraging clients to use proper hand hygeine C. Teaching clients to disconnect their oxygen when getting out of bed to walk D. Encouraging use of the call button E. Maintaining proper fluid intake

A, B, D, E Standard safety measures include encouraging the use of the call​ button, maintaining fluid​ intake, preventing infection through the use of soap or hand​ sanitizer, and letting the nurse know if pain increases or condition changes. It is unsafe to encourage clients to ambulate without supportive care such as oxygen or intravenous fluids.

An older adult client is being screened for hearing loss. Which signs should alert the nurse to hearing​ loss? Select all that​ apply. A. Unsociable behavior B. Depression in the client C. Increased mobility D. Difficulty understanding speech E. Increased forgetfulness

A, B, D, E The older adult client with a hearing impairment may be described as​ unsociable, increasingly​ forgetful, and depressed. Functional problems such as reduced mobility are also associated with hearing loss. Nurses need to be alert for signs of impaired​ hearing, such as difficulty understanding verbal communication.

The nurse is providing education for a parent of a toddler about interventions to prevent disease. Which topic of information should the nurse include in the​ teaching? Select all that​ apply. A. Prevention of lead exposure in the home B. Exposure to secondhand smoke C. Discipline for undesired behavior D. Rest and sleep E. Scheduled dental visits

A, B, D, E Topics of information to include in the teaching of interventions to prevent disease in a toddler include obtaining adequate rest and​ sleep, scheduled dental​ visits, exposure to secondhand​ smoke, and preventing lead exposure in the home. Strategies to prevent injury include discipline for undesired behavior and help with food choices.

Which nursing intervention is appropriate when providing care for a client with hearing​ impairment? Select all that​ apply. A. Restating sentences when the client has difficulty understanding B. Using the dominant hand for intravenous (IV) placement C. Replacing batteries in hearing aids regularly as needed D. Discussing appropriate communication techniques E. Encouraging the client to discuss the effect on activities of daily living (ADL)

A, C, D, E Appropriate nursing interventions for a client with hearing impairment include encouraging the client to discuss the hearing loss and the effect it has on​ ADLs, replacing hearing aid batteries regularly and when​ needed, discussing appropriate communication​ techniques, and restating sentences when the client has difficulty understanding. It is not appropriate to place an IV in the​ client's dominant​ hand, because it may be needed for communication.

Which action by the nurse risks a needlestick​ injury? Select all that​ apply. A. Recaps a dirty needle B. Gives several shots every day C. Attempts to put a needle into a full sharps container D. Uses improper hand techniques E. Places a needle in an unapproved disposal device

A, C, D, E If nurses use proper​ handling, delivery, and disposal​ techniques, they can very safely administer many shots throughout the day.​ However, recapping a dirty needle presents a risk for not only a needlestick but contamination from​ HIV, hepatitis, or other diseases. Using improper hand technique creates a risk that fingers will get in the way. If the nurse tries to put a dirty needle in a full sharps​ container, it can ricochet back and stab the nurse.​ Finally, disposing of a needle in the trash is dangerous because it could lead to needlestick injuries in environmental workers.

The nurse is discussing factors that are attributed to allergic contact dermatitis with a client. Which factor should the nurse include in the​ discussion? Select all that​ apply. A. Exposure to plants B. Dry environment C. Exposure to perfumes D. Infrequent hand washing E. Exposure to soap

A, C, E Factors that are attributed to allergic contact dermatitis include​ soap, plants, and perfumes. Dry environments and infrequent hand washing are not associated with allergic contact dermatitis.

The nurse is caring for a client at risk for a pressure injury. Which action should the nurse use to maintain the skin​ integrity? Select all that​ apply. A. Scrubbing the skin to clean it thoroughly when bathing B. Avoiding exposure to high humidity C. Cleaning the skin immediately if exposed to urine or feces D. Assessing the skin upon admission and then daily using the same screening tool E. Treating dry skin with moisturizing lotions directly applied to moist skin after bathing

A, C, E To maintain skin integrity for clients at risk for pressure​ injuries, assess the skin upon admission and then​ daily, using the same screening​ tool; treat dry skin with moisturizing lotions directly applied to moist skin after​ bathing; and immediately clean the skin if exposed to urine or feces. Do not scrub the​ client's skin when​ bathing; instead, minimize the force and friction applied to the skin to prevent injury. Avoid exposing the client to cold and low humidity.

Question content area top Part 1 The nurse is teaching a class about workplace violence. Which example of violence should the nurse​ include? Select all that​ apply. A. A family member who threatens to shoot the receptionist B. A healthcare provider who is convicted of domestic violence C. A client who throws his tray at the aide D. A nurse whose husband hits her every evening E. A staff member being bullied by several people on the unit

A, C, E Workplace violence is defined as any threatening action or violent act that takes place in a workplace. The client who throws his tray at​ staff, the family member who threatens a staff​ member's life, and staff members bullying a fellow employee are all examples of workplace violence. The examples of domestic​ violence, whether the employee is a perpetrator or a​ victim, are not workplace violence because they take place in the home and not in the workplace.

A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. Which stage should the nurse document this ulcer to​ be? A. Stage 2 B. Unstageable C. Stage 3 S. Stage 4

B A stage 4 pressure injury may be covered with eschar but cannot be evaluated if the wound bed is obscured. Eschar is not present in stage 2. Stage 3 pressure injuries may have eschar​ present, but tissue damage is limited to the subcutaneous tissue.

The nurse finds a​ 14-year-old client watching MTV at full blast. Which safety issue should the nurse address with the​ client? A. The noise is making it hard for the nurse to chart B. Adolescents need to be reminded that loud music can lead to hearing loss C. It is not wise for the client to argue with their parents about watching MTV D. It is inappropriate for the client to watch MTV

B Although the noise may be disturbing the​ nurse's work and the​ client's parents may not want the client to watch MTV at high​ volume, these are not the safety concerns the nurse needs to address. Listening to music and television at a​ high-decibel volume can lead to hearing loss.

The nurse is reviewing the chart of a client who is pregnant and reports​ "red patches of skin that​ itch." Which assessment finding should the nurse​ anticipate? A. Seborrheic dermatitis B. Eczematous skin changes around the neck C. Lacy exanthema on the cheeks D. Scaly rash on the chest

B Atopic eruption of pregnancy is a common​ pregnancy-specific skin disorder that is characterized by eczematous skin​ changes, most often around the neck and flexor surfaces of the body. A scaly rash on the​ chest, lacy​ exanthema, and seborrheic dermatitis are not associated with pregnancy.

The nurse is working with a nursing assistive personnel​ (NAP) to reposition a client who is immobile and has been lying on the left side. For which action by the NAP should the nurse​ intervene? A. Looks at the skin over bony prominences on the left side B. Asks for help pulling the client back up to the head of the bed without a draw sheet C. Places pillows under the client's legs to keep heels off the bed D. Places a foam wedge under the client's left hip

B Clients should not be pulled up in​ bed, as shearing forces and friction can break down skin tissue. Clients should be moved using a drawsheet or an assistive device. It is appropriate for the foam wedge to be placed under the​ client's left side. The skin over bony prominences on the left side should be inspected when the client is turned. It is appropriate to use pillows to keep the​ client's heels off the bed.

A family is learning to communicate with a member who has hearing loss. Which technique uses hand shapes to represent​ sounds? A. Sign language B. Cued speech C. Oral approach D. Total communication

B Cued speech uses eight hand shapes that represent groups of consonant sounds and four positions about the face that represent groups of vowel sounds. The oral approach uses only spoken language for​ face-to-face communication. Total communication uses speech and​ sign, fingerspelling, lip​ reading, and residual hearing simultaneously. Sign language is a separate language that allows the user to communicate quickly and accurately with others who understand signs

A client who has been sedated and on mechanical ventilation for several days is on a​ low-air-loss bed;​ however, the client has a localized purple area of discoloration over the coccyx that does not blanch. Which pressure injury should the nurse suspect for this​ client? A. Bruising B. Suspected deep tissue injury C. Stage 1 pressure injury D. Stage 3 pressure injury

B Deep tissue injury is suspected when intact skin has a localized purple discoloration and does not blanch when pressed. A thin blister or eschar can develop very quickly. The assessment does not describe bruising. A stage 1 pressure injury has intact skin with localized redness that does not blanch when pressed. A stage 2 pressure injury has a shallow open wound or blister without sloughing.

The nurse is planning a community event about hearing loss. Which statement should the nurse​ include? A. Hearing aids are cheap and easy to obtain B. Denial of hearing loss is a common issue C. Hearing loss does not affect mobility D. Hearing loss causes senility

B Denial of the hearing deficit is a common issue. Hearing loss does not cause​ senility, but it can affect interactions with others. Hearing aids are expensive and not easy to obtain if there are financial concerns. Hearing loss does affect mobility.

The nurse is making a home visit and is wearing a scrub​ top, scrub​ pants, and a windbreaker when the outside temperature is 45°F. Which safety concern should the nurse consider regarding clothing​ choice? A. The nurse will be too warm in this outfit B. The nurse should dress in layers in case the home is poorly heated C. The nurse should wear business attire D. The nurse's clothing is appropriate for the weather

B Home care nurses need to protect their own health. They often enter poorly heated or cooled homes. Their attire should provide appropriate thermoregulation even if the client surroundings are dangerous to health.

The nurse reviewing a​ newborn's chart notes Mongolian spots found on a prior assessment. Which describes the​ nurse's understanding of the​ etiology? A. Immune-mediated B. Congenital C. Minor trauma D. Dilated blood vessels

B Mongolian spots are​ congenital, non-blanching, hyperpigmented patches most commonly seen over the lumbosacral area. Mongolian spots do not result from minor​ trauma, are not​ immune-mediated, and do not occur due to dilated blood vessels.

The nurse is teaching new mothers about safe sleeping for newborns. Which recommendation should the nurse​ include? A. Keep newborns on their stomachs while in the crib and cover them with a warm blanket B. Dress newborns in warm clothing and place them on their backs while in a crib C. Place newborns on their sides and cover them with a light blanket D. Cover newborns up to the shoulder with a warm blanket and put them on their backs

B Research has shown that the best way to prevent sudden infant death syndrome​ (SIDS) is to place infants in a crib or bassinet on their backs. Dress the infant in warm clothing and do not use blankets because they could move out of position and smother the infant. Infants should not be placed on their stomachs or sides.

The nurse is assessing a patient for risk for pressure injury. Which of the following is not assessed in the Braden​ Scale? A. Nutrition B. Mini mental exam C. Activity D. Sensory perception

B The Braden Scale scores for sensory​ perception, moisture,​ activity, mobility, and nutrition. Even though sensory perception is affected by patient cognitive​ status, it is not fully assessed in the Braden Scale.

The nurse is caring for a pregnant client hospitalized with preeclampsia who can only walk with supervision. Which is the most important safety measure the nurse should teach the client to prevent​ injury? A. Elevating the legs B. Using the call button C. Drinking fluids D. Keeping the television on

B The most important risk to pregnant women and the fetus is the risk of falls. The nurse should encourage the use of the call button. The client is on bedrest and needs to walk with​ assistance, so she needs to communicate with staff if she needs to use the bathroom.

A client has a​ follow-up appointment for treatment of a pressure injury. Which client outcome should indicate to the nurse that treatment goals have been​ met? Select all that​ apply. A. The client's BMI is 16, and the weight is down by 4 pounds B. The client is enrolled in a smoking cessation program C. The wound has decreased in size D. The client and family demonstrate an understanding of preventive care measures E. There is greenish exudate on the pressure

B, C, D The client and family demonstrate an understanding of wound​ care, the wound has decreased in​ size, and the client has enrolled in a smoking cessation program indicate that nursing interventions and education have been effective. Greenish exudate indicates a possible infection. The​ client's decrease in weight indicates that nutrition may not be adequate for optimal wound healing and maintenance of proper weight.

The nurse taught a group of high school students actions to prevent injury. Which student comment indicates an understanding of the​ teaching? Select all that​ apply. A. I do not need to wear a seat belt as a passenger in a car B. I hate it, but I will wear a helmet when riding my bike C. If I feel really down, I need to talk to my parents about it D. I can talk to a teacher if I am faced with peer pressure to use drugs E. I should not get into a car when the driver has been drinking

B, C, D, E Nursing actions to reduce the risk for unintentional injury in the adolescent include teaching on the use of seat belts and​ helmets, discussing drug and alcohol use and risk for​ suicide, and discussing the risk for traumatic brain injury. The student who states there is no need to wear a seat belt as a passenger in a car would require further teaching. The statements of the other students indicate that teaching has been effective.

Which nursing intervention is appropriate for a client with hearing​ loss? Select all that​ apply. A. Encouraging coughing B. Providing information on types of hearing loss C. Repeating important information D. Encouraging interactions with friends and family E. Replacing batteries in hearing aids as needed

B, C, D, E Providing information on types of hearing​ loss, replacing batteries in hearing aids as​ needed, encouraging interactions with friends and​ family, and repeating important information are interventions the nurse would perform in a client with hearing loss. Coughing is not encouraged in a client with hearing loss.

The nurse identifies that a client is at risk for impaired skin integrity. Which intervention should the nurse add to this​ client's plan of​ care? Select all that​ apply. A. Keep the head of the bed elevated more than 30 degrees B. Inspect the skin every day C. Avoid massaging bony prominences D. Place the client in the side-lying position only E. Use positioning devices

B, C, E Using positioning devices such as pillows or foam wedges to protect bony​ prominences, not massaging bony​ prominences, and inspecting the skin daily help prevent skin breakdown. A​ side-lying position or keeping the head of bed elevated more than 30 degrees can put pressure on specific body areas.

A client is in the​ high- Fowler position to facilitate breathing. Which body pressure area should the nurse be most concerned​ about? A. Zygomatic bone B. Ilium C. Knee D. Heels

D A client in Fowler position has pressure on the​ heels, pelvis,​ sacrum, and vertebrae. A client in the lateral position has pressure on the knee and ilium. A client in the prone position has pressure on the zygomatic bone.

The nurse is caring for clients who have dementia in a locked unit. Which is an important safety issue for the nurse to remember during daily​ work? Select all that​ apply. A. If the unit is locked, the environment is safe and no issues exist B. Cognitively impaired adults are at risk for falls C. Residents should be allowed to leave the unit independently D. Medications should be locked away to prevent impaired clients from accidental ingestion and errors E. Residents need regular exercise to maintain muscle strength

B, D, E There are many safety risks to address even if the unit is on lockdown.​ First, clients should not be allowed to leave​ unaccompanied; by​ definition, they need to be under​ supervision, or they would not be placed in this unit. Risks on the unit include the​ following: fall risks due to cognitive​ impairment; fall risks from muscle atrophy and achy​ joints, which can be mitigated by regular​ exercise; and the risk of impaired residents getting into medication.

The nurse is caring for a client with impaired mobility. Which concern regarding tissue integrity should the nurse​ address? Select all that​ apply. A. Increased susceptibility to microorganisms B. Skin breakdown C. Allergic response D. Production of exudate E. Pressure ulcer formation

B, E The effects that impaired mobility have on tissue integrity include skin breakdown and pressure ulcer formation. The immune system mediates an allergic response. Exudate is a response to infection. Increased susceptibility to microorganisms may result from a compromised immune system.

Which assistive device should the nurse expect to be ordered for an older client who is unsteady when​ ambulating? A. Cane B. Lofstrand crutches C. Walker D. Axillary crutches

C For​ older, unsteady​ adults, the best assistive device for ambulation is a walker. A walker provides maximum stability for the client. Crutches can be unsteady for older adults to​ use, and a cane is used only when a minimum amount of support is required.

A client has been diagnosed with severe hearing loss and otosclerosis. Which treatment should the nurse expect will be​ prescribed? A. Hearing aid B. Tympanoplasty C. Stapedectomy D. Antibiotics

C Stapedectomy, the removal and replacement of the​ stapes, is used to treat hearing loss related to otosclerosis. With​ tympanoplasty, structures of the middle ear are reconstructed to improve conductive hearing deficits. A hearing aid may not restore hearing in otosclerosis. Otosclerosis is not an​ infection, so antibiotics would not be useful.

The nurse is caring for an older adult client who is significantly underweight. Which intervention should the nurse include in the plan of care for the client to maintain skin​ integrity? A. Explain the need to receive adequate exposure to sunlight B. Instruct the client to avoid the use of topical sun lotion C. Review safety strategies to prevent injuries and falls D. Recommend daily exercise followed by thorough bathing

C The intervention the nurse will include in the plan of care to help maintain the skin integrity of the older adult client who is significantly underweight is reviewing the safety strategies to prevent injuries and falls. Avoiding topical skin lotions is applicable if they contain alcohol due to the drying effect alcohol has on the skin. Daily bathing may contribute to dry skin. Adequate exposure to sunlight does not contribute to the maintenance of skin integrity.

The nurse notes that a client appears to have an integumentary infection. Which diagnostic test should the nurse anticipate will be​ prescribed? A. Patch test B. Punch biopsy C. Wood lamp D. Skin shaving

C The nurse anticipates a Wood lamp test to be prescribed to identify an integumentary infection. A patch test is used to identify an allergy. Punch biopsy and skin shaving are procedures used to obtain a skin biopsy.

The nurse is reviewing the chart of a client diagnosed with neurofibromatosis. Which change in skin pigmentation should the nurse anticipate finding based on the​ client's diagnosis? A. Actinic keratosis B. Acanthosis nigricans C. Cafe au lait spots D. Hemangioma

C The nurse can expect to find​ café au lait spots on the skin of the client who is diagnosed with neurofibromatosis.​ Café au lait spots are hyperpigmented​ freckle-like macules that can vary in color from light brown to dark​ brown, with borders that may be smooth or irregular. A hemangioma is the most common tumor of infancy. Lesions may be superficial or deeper and vary in color. Actinic keratosis is precancerous changes in skin cells that occur from many years of sun exposure. Hyperglycemia is a common cause of acanthosis​ nigricans, which is characterized by​ dark, thickened, velvety discoloration in body folds and​ creases, usually around the​ neck, axilla, and groin.

The nurse is helping a client who has dexterity concerns with hearing aid selection. Which type of hearing aid should the nurse​ recommend? A. Pink noise-masking device B. Canal hearing aid C. Behind-ear hearing aid D. In-ear hearing aid

C The​ behind-ear hearing aid allows finer adjustment of the level of amplification and is easier for clients to manipulate. The​ in-ear and canal hearing aids require more dexterity to operate. A pink​ noise-making device helps clients with tinnitus.

The nurse is caring for a client with Down syndrome who likes to say​ "hi" to everyone and strike up conversations. Which important safety information should the nurse teach the​ caregivers? A. Make sure to tell the client to shake hands with strangers B. Tell the client not to bother strangers C. Monitor the client's interactions to make sure the client is engaging with safe people D. Keep the client in a restrictive environment

C The​ client's caregivers will need to monitor the​ client's interactions with strangers because the client may have no awareness that some people can be dangerous. The client has a right to be in the least restrictive​ environment, and if the​ client's social interactions can be safely​ supervised, socialization is beneficial for the client. Teaching the client to shake hands is not a safety consideration. Telling the client not to bother strangers is not therapeutic and could cause harm to the​ client's feelings.

The nurse is caring for a client who presents with symptoms of carpal tunnel syndrome that occurred in the workplace. Which intervention is appropriate for the nurse to include in the plan for teaching to prevent further​ injury? A. Incorporate exercise activities B. Implement integrative therapies C. Use of ergonomic aids D. Schedule an annual physical assessment

C Using ergonomic aids when using the computer is an appropriate intervention to prevent further injury such as carpal tunnel syndrome. Integrative therapies are not an intervention to prevent workplace​ injury; they are used for relaxation. The healthcare provider should be consulted prior to implementing any exercise activity. Scheduling an annual physical is an intervention to prevent disease.

The nurse notes circular lesions on a​ client's upper back. Which condition should the nurse consider prior to​ examination? Select all that​ apply. A. Contact dermatitis B. Herpes zoster C. Tinea versicolor D. Ringworm E. Poison ivy

C, D The circular lesions may be attributed to either ringworm or tinea versicolor. Circular lesions are not characteristic of poison​ ivy, herpes​ zoster, or contact dermatitis.

The hospital uses a common disinfectant wipe that is rumored to cause cancer. Which appropriate step should the hospital take to ensure worker and community​ safety? Select all that​ apply. A. Instruct workers to stop disinfecting surfaces until the safety issue is solved B. Throw all the wipes away in the garbage C. Encourage use of gloves while handling hazardous substances D. Research the effectiveness of safer disinfectants and replace the hazardous chemicals E. Join GO Green to learn about safe environmental disposal of hazardous substances

C, D, E The hospital should investigate the safety of this product and look for safer disinfectants if needed. In the​ meantime, employees should be instructed to use gloves to minimize risk. The hospital should also join Go Green or another environmental initiative to learn about safe disposal of hazardous medical waste.​ However, discontinuing disinfecting practices until safer alternatives are found will increase the risk of​ healthcare-associated infections​ (HAIs). Throwing wipes away in the garbage could pose an environmental risk if they are indeed carcinogenic.

While applying lotion to the skin of an older adult​ client, the client asks why it is more important to take better care of the skin now than at a younger age. Which aspect of integumentary changes in older adult clients should the nurse include in the​ response? Select all that​ apply. A. Increased efficiency of blood circulation to skin B. Faster wound healing C. Greater sensitization to allergens D. Impaired skin barrier E. Decreased turnover of the outer skin layer

C, D, E The integumentary changes that occur in older adult clients include impaired skin​ barrier, greater sensitization to​ allergens, and a decreased turnover of the outer skin layer. Wound healing is slowed and circulation to the skin decreases.

The nurse is assessing diffuse bullae and vesicles on a​ client's hands and arms. Which question should the nurse ask the​ client? A. Do you have a history of psoriasis B. Do you have a history of chronic dermatitis C. Have you been scratching your skin D. Have you been in contact with poison ivy

D Bullae and vesicles are found on a client who has been in contact with poison ivy. Scales is a finding associated with psoriasis. Excoriation is a result of scratching the surface of the skin. Findings associated with chronic dermatitis include lichenification.

The nurse is caring for an adolescent female client who has begun menstruating. Which preexisting disorder should the nurse expect to be exacerbated by the hormonal changes that​ occur? A. Contact dermatitis B. Fungal tinea C. Warts D. Eczema

D Eczema is exacerbated by the hormonal changes that accompany menstruation. The incidence of warts and fungal tinea infections increase due to the involvement with sports and use of public showers. Contact dermatitis is not associated with hormonal changes that occur during menstruation.

The nurse administers a vitamin every morning to a client who is 8 months pregnant and is hospitalized for a fall. Which safety measure should the nurse understand while caring for this​ client? A. The vitamin is a placebo medicine B. The vitamin administered to help cure fall injuries C. The client will feel less anxious while taking the vitamin D. It is important for the client to continue ordinary prenatal care while in the hospital

D It is important for the mother and baby for pregnant women to continue prenatal care while they are in the hospital. The vitamin is not a​ placebo, a cure for the immediate​ condition, or an​ anxiolytic; its purpose is to maintain a safe pregnancy.

The nurse assessing a client notes the client is at risk for candidiasis. Which client behavior observed by the nurse would support this​ conclusion? A. The client used a child's brush to fix the hair B. The client washes the hands four times in an hour C. The client applies a moisturizer immediately after washing the hands D. The client is on antibiotics

D The client taking the antibiotic is at risk for candidiasis. The antibiotic alters the normal flora in the​ body, resulting in the potential for opportunistic​ infections, such as​ candidiasis, to occur. A client using a​ child's brush is at risk for parasite transmission. The client who washes the hands four times in an hour is at risk of impaired skin integrity. The client who applies moisturizer immediately after washing the hands is not at risk for​ candidiasis, and this demonstrates good skin care.

While conducting a home​ visit, the nurse observes a new mother heating the water to the proper​ temperature, placing the infant in a sink for a morning​ bath, and then walking away to collect towels and soap. Which topic should the nurse use to guide teaching for this​ mother? A. Thermoregulation issue B. Risk for developmental delays C. Risk for coping issues D. Knowledge deficit

D The mother may not be aware that the baby can drown in a sink full of​ water, so the topic of knowledge deficit is correct. The nurse would need to teach the mother about water safety for the infant. Nothing indicates the infant is having thermoregulation​ issues, so this topic would not be applicable at this time. Neither the mother nor the infant has sustained a head​ injury, so the risk for developmental delays is not applicable at this time. There is no evidence to suggest that the mother is at risk for coping issues.

The nurse is caring for a client with acne. Which condition describes the​ nurse's understanding of the classification of​ acne? A. Infectious B. Neoplastic C. Dermatitis D. Inflammatory

D The nurse caring for the client with acne understands that the classification of acne is inflammatory. Acne is not classified as infectious or neoplastic. Dermatitis is another inflammatory disorder of the skin.

The nurse is teaching a client about a newly prescribed​ medication, a macrolide​ antibiotic, to help with an ear infection. Which client statement indicates a need for further​ teaching? A. I will monitor my hearing function and call the healthcare provider if my hearing changes B. I will drink adequate amounts of fluids C. I will avoid grapefruit juice while on this medicaiton D. I will take the pills until the symptoms of my ear infection subside

D The nurse must teach the importance of finishing the full course of​ antibiotics, not just until symptoms subside. Clients on antibiotics should be taught to drink adequate​ fluids, monitor for​ ototoxicity, and be warned that taking macrolides along with grapefruit or grapefruit juice may alter the​ drug's uptake.

While assessing the skin of a client who has undergone​ surgery, the nurse observes erythema to the left scapulae. Which action should the nurse take before reassessing the skin to determine if the erythema is a pressure​ injury? A. Cover the area with a dressing B. Apply a warm blanket C. Massage the scapulae with lotion D. Reposition the client

D The nurse should reposition the client to remove pressure from the scapulae and then reassess for redness in​ one-half or​ three-fourths the time it took to create the reddened area. If the reddened area does not​ clear, the client has a stage 1 pressure injury and is not blanchable. Massaging the scapulae with​ lotion, applying a warm​ blanket, or covering the area with a dressing are not the most appropriate actions to take before reassessing the client.

The nurse is planning teaching for a client with infected contact dermatitis. Which information should the nurse include in the teaching? A. Use cold water and a mild soap to cleanse skin B. Stop antibiotics when redness disappears C. Cover the infected site with a sterile dressing D. Keep nails trimmed down

D The nurse will instruct the client to keep nails trimmed short to avoid scratching the infected dermatitis. It is not necessary to cover the infected site with a sterile dressing or cleanse the skin with cold water. The skin can be cleansed with tepid water. Antibiotics should be taken until all of the medication is completed as ordered.

A client with a deep tissue injury and white exudate develops a fever. Which test should the nurse anticipate being prescribed by the healthcare​ provider? A. Urine culture and sensitivity B. ESR C. Serum protein D. Culture and sensitivity of the wound bed

D The wound bed can be cultured to determine the organism causing the infection. ESR can determine the presence of osteomyelitis. Serum protein helps establish nutritional status. Urine culture and sensitivity will determine presence of a urinary tract infection​ (UTI).

The nurse observes sudden changes in a client during an​ assessment, including weakened vital​ signs, diaphoresis, and labored breathing. Which type of acute changes is the nurse​ observing? A. Behavioral B. Functional C. Cognitive D. Physical

D There are four types of acute changes in condition that require the use of the nursing process to address. The client is demonstrating acute physical changes as vital signs weaken and diaphoresis and labored breathing arise. The nurse can only accurately determine the extent of the change in condition by using precise assessment skills.

The nurse manager observes a new nurse talk with a client with a stroke and decreased mobility about ways to prevent pressure injures. For which statement should the nurse manager​ intervene? A. We will keep your skin clean, dry and moisturized to prevent tissue damage B. We will ensure your diet contains adequate calories, protein, vitamins and iron C. You can help by using your right side to make small adjustments to your left side every 30 minutes or so D. Due to decreased mental status, you will need to be turned every 2 hours

D There is no indication the client has decreased mental status. The client should be turned and repositioned every 2 hours. Keeping the skin​ clean, dry, and moisturized will help prevent tissue damage. A diet with adequate​ calories, protein,​ vitamins, and iron will help to prevent skin breakdown. The client can be encouraged to participate by helping to move the left side every​ 15-30 minutes. Even small adjustments of​ 10-20 degrees can prevent tissue injury.

A client with deep tissue damage develops eschar. Which procedure should the nurse anticipate being​ prescribed? A. Application of a petroleum ointment B. Application of a moisture-retaining protective dressing C. Application of a barrier cream D. Surgical debridement

D When eschar has​ formed, surgical debridement and removal of necrotic material is necessary. Application of a barrier cream is appropriate for intact skin. Use of petroleum ointment is not appropriate. Application of a​ moisture-retaining protective dressing is appropriate for a pressure injury without eschar or after the eschar has been surgically removed.

Which is the major cause of sensorineural hearing deficit? A. Impacted cerumen in the ear canal B. Noise exposure C. Obstruction of the external ear canal D. Edema in the ear canal

B A major cause of sensorineural hearing deficit is damage to the hair cells of the organ of Corti from noise exposure. The most common cause of conductive hearing loss is obstruction of the external ear canal. Impacted cerumen and edema of the canal lining also cause conductive hearing loss.

The nurse is reviewing the prescription for a client requiring a surgical procedure to remove cataracts. The nurse understands that which collaborative team member will most likely perform the​ client's surgery? A. Ophthalmologist B. Otolaryngologist C. Optometrist D. General surgeon

A Cataracts are a clouding of the eye lens that can be corrected by surgery. An ophthalmologist will perform the surgical procedure to remove the​ client's cataracts. An optometrist is trained to perform eye exams and prescribe corrective lenses to correct ordinary problems with visual acuity. A general surgeon does not remove cataracts. An otolaryngologist is trained to diagnose and treat​ ear, nose, and throat disorders and can perform surgery if necessary.

The nurse is performing a focused health history for a client diagnosed with a herniated disc. Which information is most appropriate for the nurse to include in this​ history? A. Work and recreational activities B. Diet recall C. Ethnicity D. Drug use

A Frequent twisting and lifting are significant risk factors for herniated​ disc, so work and recreational activities should be assessed. Substance​ abuse, diet and​ nutrition, and genetic risk factors common to specific ethnicities can be important components of a health history but are not particularly pertinent to herniated discs.

A client in significant pain from metastatic bone cancer begs the nurse to help him die. How should the nurse respond? A. Euthanasia is illegal, but I'll have the pain management team come to see you immediately B. Let me get the appropriate paperwork for you to sign C. Let's talk about hospice care D. You must have your attorney get a court order and bring it to the hospital first

A It is important for the nurse to address and appropriately manage the​ client's pain, even though active euthanasia is illegal in all 50 states. Signing paperwork or getting a court order will not help the client in this situation. Talking about hospice​ care, though it may be​ appropriate, dismisses the​ client's concern at this moment.

A client with eroding cartilage of the left knee asks the nurse why bruising is absent because bruising was present when they injured their knee a few months ago. Which response by the nurse is​ accurate? A. Cartilage does not contain blood vessels B. Cartilage is eroded because blood vessels are harmed C. This injury damaged the blood vessels D. The cartilage has eroded all blood vessels

A Ligaments and tendons contain blood​ vessels, but cartilage does not. Because of​ this, bruising will be absent with cartilage erosion. The previous injury caused a bruise because either ligaments or tendons were injured. Cartilage erosion does not damage blood vessels. Cartilage does not erode blood vessels. Cartilage does not erode because blood vessels are harmed.

A client is prescribed a nonsteroidal​ anti-inflammatory drug​ (NSAID) for arthritis. Which information should the nurse teach the client about this​ medication? A. Report any gastrointestinal distress to the healthcare provider B. Avoid driving or using machinery while taking this medication C. This medication may cause confusion and hallucinations D. Take this medication with calcium supplements

A NSAIDs can cause gastrointestinal​ distress, which should be reported to the healthcare provider. Calcium supplements do not need to be taken with NSAIDs. Antispasmodics can cause confusion and hallucinations. Driving and machinery use should be restricted when taking an antispasmodic.

The hospital administrator is expanding the palliative care area in a major metropolitan city hospital. When planning for this care area, which member of the healthcare team should the administrator realize is most likely to notice subtle changes in the client's condition and communicate them to the rest of the team? A. The nurse B. The healthcare provider C. The social worker D. The spiritual advisor

A Nurses interact with clients most​ frequently, so they are responsible for communicating changes to the rest of the healthcare and collaborative team. The nurse must be vigilant to these changes and ensure appropriate and timely communication with the healthcare​ provider, family​ members, social​ workers, psychologists, or spiritual advisors.

The nurse is caring for a pediatric client with a terminal illness. When should palliative care be initiated for this child? A. Upon diagnosis with a life-threatening illness B. When officially diagnosed as terminal C. At the time the parents are prepared D. As death approaches

A Palliative care is best initiated when a child is first diagnosed with a​ life-threatening illness. This ensures that appropriate and rational care planning can occur early in the course of the​ child's disease when there​ isn't a crisis. Waiting until the child is diagnosed as terminal or death is imminent may cause conflict down the line. The parents may never decide that they are ready for palliative​ care, which can also cause conflict or poor care planning.

The nurse prepares an educational program on palliative care for a group of oncology nurses. For which age group should the nurse emphasize that palliative care is often neglected? A. Infants B. Older adults C. Children D. Adolescents

A Palliative care tends to be neglected in infants and very young​ children, though they should receive this type of care in the same way that adults do. Nurses are more likely to identify​ children, adolescents,​ adults, and older adults as potential candidates for palliative care.

Which is the greatest risk factor associated with hearing​ impairment? A. Gender B. Age C. Race D. Occupation

B Age is one of the greatest risk factors associated with hearing impairment. Caucasians are twice as likely as African Americans to have hearing loss. Hispanics are less likely than​ non-Hispanics to experience difficulty with hearing. Individuals who are consistently exposed to loud noises on their job are at greater risk of developing hearing impairment. A relation between gender and hearing impairment has not been identified.

A nurse is caring for a client who delivered a healthy baby boy by cesarean birth 24 hours ago. The nurse notes that the client correctly uses her arms to help transfer in and out of bed. Which type of exercise is the client demonstrating when performing this activity? A. Isotonic B. Aerobic C. Anaerobic D. Isometric

A The client who uses her arms to aid in transfer is demonstrating isotonic activity. Aerobic​ exercise, such as running or​ hiking, conditions the cardiovascular system. Isometric activity is that in which the joint​ doesn't move but the muscle contracts​ (e.g., wall​ sits). Anaerobic exercise utilizes anaerobic pathways to provide additional energy for a short time because muscles are unable to use enough oxygen from the bloodstream. Sprinting is an example of anaerobic exercise.

The nurse is caring for a client who has experienced a permanent hearing loss. Which referral is most beneficial to assist the client in adjusting to the sensory​ deficit? A. Class for American sign language B. Audiologist C. Otolaryngologist D. Ophthalmologist

A The nurse can obtain a referral for the client to attend a class for American sign language. The class for American sign language will help facilitate an adjustment to the sensory loss and enable the client to communicate. An audiologist or otolaryngologist is not the most beneficial referral to assist the client in adjusting to the sensory deficit. An ophthalmologist treats eye disorders.

The nurse has been asked to serve as a point person for a family with a child who is dying in the PICU. Which function should the nurse prepare to perform in this role? A. Develop a trusting relationship with the parents B. Articulate the family's wishes to the healthcare team C. Organize care before, during and after death D. Address the emotional and informational needs of the family

A The point person will develop a trusting and unique relationship with the parents while their child is in the PICU. The family advocate will help to articulate the​ family's wishes to the healthcare team. The family supporter will address the emotional and informational needs of the family. The​ end-of-life coordinator will organize care​ before, during, and after death.

The nurse is assessing a visually impaired​ client's home environment for safety. Which finding is most concerning for the​ nurse? A. Throw rugs B. Colored rims on dishes C. Telephone with large print dial D. Chairs pushed under the table

A Throw rugs place the client at risk for falling. Colored rims on​ dishes, a telephone with​ large-print dial, and chairs pushed under the table are safe environmental findings for the client who is visually impaired.

The nurse is caring for a client with​ open-angle glaucoma who is concerned about treatment of the condition. Which statement by the nurse most accurately describes the treatment plan for the​ client? A. You will be prescribed medication for treatment B. There currently is no treatment for glaucoma C. The optometrist will discuss the plan for treatment D. Cataract removal will help resolve the glaucoma

A Treatment for glaucoma includes medications to control intraocular pressure and preserve vision in​ open-angle glaucoma. Surgery is also used in the treatment of glaucoma. Cataracts are not related to glaucoma. An ophthalmologist will be included in the treatment plan. An optometrist is trained to perform eye exams and prescribe corrective lenses to correct ordinary problems with visual acuity.

The nurse is caring for an adult client with hyperlipidemia. Which assessment finding is most associated with the​ client's diagnosis? A. Xanthelasma B. Exophthalmos C. Ptosis D. Hordeolum

A Yellow plaques noted on or near the lid margins are referred to as xanthelasma and may indicate high lipid levels. Ptosis is a drooping of an eyelid that is associated with a stroke or neuromuscular disorder. A hordeolum is a sty generally caused by a staphylococcal infection. Exophthalmos is an unusual widening of the lids that is often associated with hyperthyroid conditions.

An adolescent client with a terminal illness wishes to discontinue further treatment. Which action should the nurse take at this time? A. Arrange a meeting between the teen, the parents and the healthcare team B. Explain that there is nothing that can be done until the teen turns 18 C. Contact the healthcare provider for a DNR/DNI order D. Give the consent form to the teen to sign

A ​Teens, especially teens with a chronic or terminal medical​ illness, have a strong desire for autonomy and are cognitively able to participate in their​ care, despite the law not allowing them to make formal decisions until they turn 18. The nurse should arrange a meeting between the​ teen, the​ parents, and the healthcare team to discuss the​ teen's feelings and wishes and the different options available.

A community health nurse is providing education to a group of adults about the types of exercise that promote health. Which statement will the nurse include in the teaching? Select all that apply A. Isotonic exercises like walking and swimming are also known as dynamic exercises B. An example of an anaerobic exercise is weightlifting C. The talk test may be easier to use than the heart rate calculation for determining effort in aerobic exercise D. Isometric exercise or isolated muscle contraction, creates an increase in blood flow to all parts of the body E. Anaerobic exercises are exercises where the amount of oxygen taken into the body during exercise is greater than that used to perform the activity

A, B, C An example of anaerobic exercise is weightlifting. Isotonic exercises are also known as dynamic exercises. The talk test may be easier to use than the​ heart-rate calculation for determining effort in aerobic exercise. Aerobic​ exercises, not​ anaerobic, are exercises where the amount of oxygen taken into the body during exercise is greater than that used to perform the activity. Isometric exercise causes a slight increase in heart rate and cardiac​ output, but it causes no noticeable increase in blood flow to other parts of the body.

The nurse uses Maslow's hierarchy of needs to help identify a client's care issues. What should the nurse recall as being the highest level of this hierarchy? A. Love and belonging B. Self esteem C. Self Actualization D. Safety and Security

B Self actualization According to​ Maslow's hierarchy of​ needs, the highest level of basic human need is​ self-actualization. The other answer choices are levels of the​ hierarchy; however, they are incorrect choices.

The nurse is caring for a pregnant client who appears to be experiencing discomfort related to the pregnancy. What content should the nurse include in the teaching plan to enhance comfort for this client? Select all that apply. A. Getting enough rest B. Drinking enough water C. Eating a balanced diet D. Refraining from daily exercise E. Taking over-the-counter pain medication

A, B, C The pregnant client who is experiencing discomfort related to pregnancy should be taught the importance of adequate​ nutrition, hydration, and sleep and rest. The pregnant client should not be encouraged to take​ over-the-counter pain medication unless directed by the healthcare provider. The nurse would provide tips on daily​ activity, but the pregnant client would not need to refrain from daily exercise.

A client​ states, "My healthcare provider says my problem with mobility is with my connective tissues. What are connective​ tissues?" Which structure should the nurse include in the​ response? (Select all that​ apply.) A. Cartilage B. Tendons C. Ligaments D. Muscle E. Bones

A, B, C ​Tendons, cartilage, and ligaments are all connective tissues. Tendons connect bone to muscle to cause movement. Cartilage is flexible connective tissue and is less flexible than muscle but not as stiff as bone. Ligaments connect bones to other bones to form a joint and serve to strengthen and stabilize the joint. Bones provide the framework for the skeletal structure. Muscles contain fibers that move the bones.

The nurse is planning care for a client with a terminal illness who is nearing the end of life. Which action should the nurse take to ensure the client receives the highest quality of care? Select all that apply. A. Stay with the client until intravenous pain medications takes effect B. Offer family members a quiet area to express emotions C. Remind the healthcare provider to discuss symptom management with the client and family D. Explain interventions to the client and family before performing E. Suggest that family members return home to get rest

A, B, C, D Nurses play an important role in providing quality​ end-of-life care to clients and their families by facilitating communication among​ clients, families, and​ providers; providing emotional​ support; and treating clients and their families with respect. The nurse should offer family members a quiet area to express​ emotions, explain interventions before performing​ them, stay with the client until pain medication takes​ effect, and remind the healthcare provider to talk with the family and client about symptom management. While it is important for family members to receive adequate​ rest, the nurse would not suggest they return home to do this. If rest is​ needed, the family can be provided with a quiet place to recharge.

A client is complaining of difficulty hearing. Which medications on the​ client's home medication list would alert the nurse of the potential risk for hearing​ impairment? Select all that​ apply. A. Alkylating agent B. Salicylate C. Loop diuretic D. Aminoglycoside E. Angiotensin-converting enzyme inhibitor

A, B, C, D Some medications can cause hearing disorders.​ Aminoglycosides, alkylating​ agents, loop​ diuretics, and salicylates can all cause hearing impairment.​ Angiotensin-converting enzyme inhibitors are not associated with hearing loss.

A client reports pain as being an 8 on a scale from 1 to 10. Which finding should the nurse expect when assessing this client? Select all that apply. A. Posturing B. Verbal complaints C. Abnormal gait D. Facial grimaces E. Fever F. Guarding

A, B, C, D, F (not fever)

The family of a client with mobility difficulties asks the​ nurse, "What​ age-related changes to the musculoskeletal system should we expect our father might​ experience?" Which change should the nurse include in the​ response? Select all that apply A. Flexed position of hips B. Ligament tears C. Increased bone density D. Decreased joint fluid E. Muscle fiber atrophy

A, B, D, E Changes in the musculoskeletal system that occur with aging include tears in​ ligaments, atrophy of muscle​ fibers, decreased joint​ fluid, and a flexed position of the hips. Bone density decreases with aging.

A nurse is caring for a client who is hospitalized because of a fractured femur. The client tells the nurse that it is difficult to get any sleep while in the hospital. What action should the nurse take to minimize environmental stimuli in the hospital environment? Select all that apply. A. Placing the client in a single-bed room when possible B. Performing only essential activities in the client's room during sleeping hours C. Adjusting window coverings to block outside lights during the day and night D. Minimizing noise from staff interactions E. Keeping the client's door closed

A, B, D, E To reduce environmental stimuli in the hospital​ environment, the nurse should do all the stated​ actions, except adjust window coverings to block outside lights during the day and night. The window coverings should be adjusted only at​ night; during the​ day, the window coverings should be left open to let in natural light.

A client asks the home care nurse about the difference between acute and chronic illness. Which information does the nurse give the client about characteristics of chronic illness? Select all that apply A. Chronic illness can have remissions B. Chronic illness can remain for life C. Chronic illness does not have exacerbations D. Chronic illness usually lasts 6 months or more E. Chronic illness has a slow onset

A, B, D, E Chronic illness can have both remissions and exacerbations. It usually lasts 6 months or more and can remain for life. It has a slow onset.

The nurse begins an early ambulation routine with a client diagnosed with altered mobility. Which benefit of early ambulation should the nurse explain to the​ client? Select all that​ apply. A. Strengthens muscles B. Improves self-esteem C. Improves skin turgor D. Promotes diarrhea E. Reduces risk of thrombophlebitis

A, B, E Early ambulation decreases the risk of complications of​ inactivity, including​ thrombophlebitis, osteoporosis, muscle​ atrophy, constipation, and urinary incontinence. It also strengthens​ muscles, increases joint​ flexibility, stimulates​ circulation, and improves​ self-esteem. Ambulation does not promote diarrhea or improve skin turgor.

A client is requesting to sign a document that designates someone to make healthcare decisions in case they are not able to do it. Which document should the nurse recommend to this client? A. DNR order B. Durable power of attorney C. Healthcare proxy D. Living will

C A healthcare proxy designates an individual to make healthcare decisions in case the client is not able. A durable power of attorney allows the selected individual to make legal decision for the client. A living will describes the​ client's treatment preferences for​ life-prolonging treatment. A DNR order is also known as a​ do-not-resuscitate order and allows the healthcare team to withhold​ life-saving measures in the event of a cardiac or respiratory arrest.

The client asks the nurse about biofield therapies to help with chronic pain. Which information should the nurse include about the use of biofield therapies? Select all that apply A. This complementary alternative therapy has no side effects or interactions with other treatments B. They balance the energy fields in the body that are disrupted by physiologic imbalances C. Biofield therapies have been around for quite a long time, but they really have no value other than people thinking that they work. D. There is a large repository of evidence that indicates the clinical efficacy of biofield therapy in effectively reducing pain E. Evidence supports the use of these therapies to help people deal with painful experiences

A, B, E Evidence supports the use of these therapies to help people deal with painful​ experiences; they have no side​ effects, nor do they interact with other​ treatments; and they balance the energy fields in the body that are disrupted by physiologic imbalances.​ However, evidence does not yet support clinical efficacy. The statement that they really have no value is a subjective opinion and should not be included in the information provided to the client.

The mother reports that their​ 9-month-old infant has had a​ fever, is​ irritable, and​ "keeps tugging on her​ ear." Which equipment should the nurse gather while preparing for the​ exam? Select all that​ apply. A. Otoscope B. Thermometer C. Tuning fork D. Ophthalmoscope E. Tympanogram

A, B, E For the assessment of an infant client with symptoms related to the​ ear, a nurse would gather a​ tympanogram, an​ otoscope, and a thermometer. A thermometer would be appropriate to assess the​ fever, and a tympanogram will measure the pressure inside the middle ear. The client is exhibiting signs of an ear​ infection, so this would be an important piece of equipment for the assessment. An otoscope is used to visualize the ear canal for discharge and the condition of the tympanic membrane and would be appropriate for this client. An ophthalmoscope is used to assess​ disorders, complaints, and injuries of the eyes and would not be needed for this client. A tuning fork is used for assessment of tactile and auditory function and would not be appropriate for this client.

The nurse reviews data collected during an assessment of a terminally ill client. Which nursing diagnosis should the nurse select as this client nears death? Select all that apply A. Comfort, impaired B. Sleep pattern, disturbed C. Fluid volume: deficient, risk for D. Nutrition, imbalanced: less than body requirements E. Tissue integrity, impaired

A, B, E The main objective for care as a patient nears death is comfort.​ Therefore, nursing diagnoses appropriate for a client nearing death include ​Comfort, Impaired; Tissue​ Integrity, Impaired​; and Sleep​ Pattern, Disturbed. While a client nearing death will have altered nutrition and fluid volume​ deficit, these would be considered manifestations and not necessarily client problems that the nurse would address at this stage.​ (NANDA-I ©​ 2014)

The nurse is testing a​ client's six cardinal fields of vision. Which cranial nerves is the nurse​ assessing? Select all that​ apply. A. Cranial nerve III (oculomotor) B. Cranial nerve IV (trochlear) C. Cranial nerve X (vagus) D. Cranial nerve II (optic) E. Cranial nerve VI (abducens)

A, B, E The nurse who is testing a​ client's six cardinal fields of gaze is assessing cranial nerves​ IV, VI, and​ III, which are involved in oculomotor movement. Cranial nerves II and X are not involved in oculomotor movement.

The nurse notes that several terminally ill pediatric clients do not have advanced care planning. The nurse should recognize which barriers are the most common ones that hinder the completion of this planning? Select all that apply A. Unrealistic parent expectations B. Differences in understanding of the child's prognosis between clinicians and parents C. Lack of financial means D. Lack of parent readiness to discuss the need for palliative care E. Lack of formal pediatric palliative care training by the healthcare provider

A, B, E The top three barriers to advanced care planning for children are unrealistic parental​ expectations, differences in understanding of the​ child's prognosis between clinicians and​ parents, and lack of parent readiness to discuss the need for palliative care. Lack of financial means and lack of formal pediatric palliative care training are other barriers for care but are not among the top three.

The nurse is developing an educational program regarding exercise for clients with chronic illnesses. What information should the nurse include? Select all that apply. A. Regular exercise can help decrease lipid levels B. Aerobic exercise decreases glycemic control C. Regular exercise improves cardiovascular health and decreases risk of developing heart disease, hypertension, stroke, and heart failure D. Exercise increases joint stability and range of motion E. Those with COPD and asthma should not participate in exercise that increases respiratory rate due to the risk of bronchospasms

A, C, D Regular exercise does decrease cardiovascular risk and decreases risk for developing heart​ disease, hypertension,​ stroke, and heart failure. Exercise also increases joint stability and range of motion. Regular exercise enhances the gut​ microbiome, which improves lipid and carbohydrate metabolism. Those with COPD and asthma should participate in aerobic exercise. Aerobic exercise​ increases, not​ decreases, glycemic control.

The nurse taught a client about ways to prevent alterations in mobility. Which client behavior indicates that the teaching has been​ effective? Select all that​ apply. A. Client consumes fresh fruits and vegetables every day B. Client smokes a half pack of cigarettes per day C. Client walks every day for 30 minutes D. Client drinks milk with every meal E. Client applies ice to inflamed joints twice a day

A, C, D The best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good​ nutrition, adequate calcium​ intake, and regular exercise. Drinking​ milk, walking, and consuming fresh produce indicate actions to prevent the development of musculoskeletal disorders. Smoking is not a healthy activity. Applying ice to inflamed joints indicates an alteration in mobility already exists.

A nurse is caring for a client with a sleep disorder. Which question should the nurse ask about the current problem? Select all that apply A. When did you discomfort start? B. Have you had past experiences that affect the way you view this discomfort? C. Which activities make the discomfort better or worse? D. How would you describe your discomfort? E. How long have you had this discomfort?

A, C, D, E Asking the client about past experiences related to how the client views the current problem would be a question the nurse would ask about health​ history, not the current problem. All other statements are correct.

The spouse of a terminally ill client who has just passed away sits at the bedside, holds the client's hand and cries softly. What action should the nurse take to support the spouse at this time? Select all that apply. A. Ask if the spouse would like to talk with someone about the client's death B. Remind the spouse that the client will need to be moved in a short while C. Ask if there is a particular funeral home that should be contacted D. Ask if there is anyone that should be contacted at this time E. Provide the spouse with water and tissues

A, C, D, E Considerations for the family at the end of life include assisting the family to cope with the​ client's health status. Interventions should focus on providing the family with emotional support and referring the family to funeral​ homes, grief​ counseling, and support groups if appropriate. The nurse should provide the spouse with water and tissues to help meet physical needs. Asking if there is anyone that should be contacted helps to meet the​ spouse's psychosocial needs. Asking about a funeral home or if the spouse would like to talk with someone about the​ client's death helps meet the​ spouse's grieving needs. Reminding the spouse that the client will need to be moved does not support any of the​ spouse's needs at this time.

The nurse cares for a client who is approaching the end of life. Which sign indicates that the client is nearing death? Select all that apply A. Increase in confusion B. Periods of intense hunger C. Restlessness D. Increase in sleeping E. Apneic periods

A, C, D, E Signs that indicate a person is nearing death include increased​ confusion, increased periods of​ sleep, apneic​ periods, and restlessness. There is a​ decreased, not an​ increased, need for food at this time.

The nurse is conducting a health interview to determine a​ client's mobility status. Which lifestyle behavior is most appropriate for the nurse to​ assess? Select all that​ apply. A. Primarily working on a computer B. Living alone C. Smoking habits D. Taking no medications E. Long distance running

A, C, E A​ client's lifestyle affects mobility status. Smoking is a negative behavior that adversely affects many aspects of an​ individual's health. Physical activity such as​ long-distance running can affect the​ joints, ligaments, and cartilage. Computer work is a sedentary activity that could potentiate the development of musculoskeletal disorders. Living alone and not taking any medication would not adversely affect an​ individual's musculoskeletal or mobility status.

A nurse is providing teaching for a client diagnosed with an olfactory deficit. Which interventions specifically related to an olfactory deficit will the nurse include in the​ teaching? Select all that​ apply. A. Review home cleaning supplies with the client B. Darken the room with shades C. Set up schedule for changing the batteries in carbon monoxide detectors D. Check the expiration date on food E. Recommend the client purchase smoke detectors with flashing lights

A, D The nurse caring for the client with an olfactory deficit will instruct the client to check the expiration dates on the food and review the safety of cleaning supplies. The client may not detect spoiled food products or recognize toxic chemical odors from cleaning supplies. Darkening the rooms with shades is appropriate for a client at risk for sensory overload. Flashing smoke detectors are beneficial for someone with a hearing deficit. Carbon dioxide is an odorless​ gas, so changing the batteries in the carbon monoxide detector does not specifically address an olfactory deficit.

The nurse is caring for a client who is in pain because of a back spasm. Which independent nursing intervention should the nurse use for this client? Select all that apply A. Applying heat or cold as appropriate B. Ordering physical therapy for the client C. Administering analgesics as ordered D. Positioning the client to promote comfort E. Providing distractions

A, D, E Independent nursing interventions for a client in discomfort include applying heat or cold as​ appropriate, providing​ distractions, and positioning the client to promote comfort. Administering analgesics and ordering physical therapy are collaborative interventions.

The nurse is developing a plan of care for a client experiencing an alteration in mobility. Which objective is most appropriate for the nurse to​ include? Select all that​ apply. A. Prevent injury B. Promote healthy relationships C. Recommend immunizations D. Promote comfort E. Promote education

A, D, E Independent nursing interventions for the client with an alteration in mobility focus on promoting education and comfort as well as preventing injury. Although promoting healthy relationships and recommending immunizations may be important for all​ clients, these nursing interventions are not specifically important to clients with alterations in mobility.

A pregnant client presents with back pain. Which condition is most likely the cause of this​ pain? Select all that​ apply. A. Stretched abdominal muscles B. Bulging discs C. Improper lifting D. Strain from the growing uterus and fetus E. Instability of the pelvis

A, D, E ​Sixty-two percent of women report back pain during pregnancy. This pain is generally caused by strain on the back from the growing uterus and​ fetus, which causes postural​ changes; abdominal weakness from stretched abdominal​ muscles; and hormonal​ changes, which loosen the ligaments in the joints of the pelvis. Bulging discs and improper lifting do not normally cause back pain in pregnancy.

A client is transferred from the critical care area to a general medical unit. What action should the nurse take first to help promote sleep? A. Ask the family to decrease the number of visits since the client has improved and needs to rest B. Assess the client's individual circadian rhythm C. Contact the healthcare provider to obtain an order for a hypnotic/sedative D. Encourage the client to take naps when able, to decrease the impact of the sleep disturbance.

B

A nurse is caring for an older adult who is hospitalized due to a fractured hip secondary to a ground-level fall. The nurse is assisting the client with oral care when the client asks the nurse, "Why am I having more issues with cavities? I always brush and floss my teeth." Which is the correct response by the nurse? A. This is a normal finding with aging because gum disease causes tooth decay B. This can happen as you age because your teeth lose enamel, making them more susceptible to damage and cavity formation C. This is not an abnormal finding with aging because you brush and floss regularly D. This can happen with aging because saliva production increases, making teeth more susceptible to cavity formation

B As a normal process of​ aging, the teeth become more susceptible to damage and decay due to the thinning of the tooth enamel. The other answer choices include responses that have incorrect​ information: saliva production does not increase​ (it decreases) with​ age; good oral hygiene​ (brushing and flossing​ regularly) would decrease the likelihood of cavity formation even with​ aging; and periodontal disease​ (gum disease) causes the loss of​ teeth, not dental caries.

The nurse assessing the lacrimal glands of a newborn observes excessive tearing in the right eye. Which most accurately describes the etiology of the assessment​ finding? A. Allergies B. Blockage of nasolacrimal duct C. Neurologic disorder D. Infection

B Excessive tearing noted during the assessment of the lacrimal gland is indicative of a blockage of the nasolacrimal duct. Tenderness and drainage are findings associated with infection. Excessive tearing is not a finding associated with allergies or a neurological disorder in a newborn.

The nurse is providing care for a child who is experiencing discomfort due to intermittent urinary catheterizations. Which should the nurse encourage the family to do during the procedure to most appropriately enhance comfort for the child? A. Hold the child while the procedure is being performed. B. Offer a distraction during the procedure C. Explain the procedure each time before it is performed to ensure understanding D. Offer the child a treat such as a sticker or a small toy after the procedure

B For the child experiencing discomfort during a procedure such as​ this, it would be most appropriate to encourage the parents to distract the child. Holding the child would likely complicate completion of the procedure and would not be the best option. While offering the child a treat or small toy after the procedure may help encourage them to cooperate with the​ procedure, it would not be the most appropriate option to enhance comfort. Explaining procedures can help to decrease​ anxiety, but doing so each time may not necessarily enhance comfort.

Which type of exercise should the nurse implement to maintain the strength of a limb with an immobilized​ joint? A. Range of motion exercise B. Isometric exercise C. Resistive exercise D. Passive exercise

B Isometric exercise is used to maintain strength when a joint is immobilized. It is performed by contracting a specific muscle group against another muscle group or immovable object. Resistive exercise is an active exercise where the client works against resistance to increase muscle strength.​ Range-of-motion exercises help maintain joint mobility during periods of restricted activity. Passive exercises are performed by a physical therapist or nurse for the client.

The nurse is providing visual screenings for​ school-age children. The nurse understands that which visual problem is most commonly diagnosed in​ school-age children? A. Accommodation B. Convergence C. Corneal light reflex D. Strabismus

B Problems with convergence are usually diagnosed in​ school-age children when they have difficulty reading and may be interpreted as a learning disability rather than a visual problem. Problems with​ strabismus, accommodation, and corneal light reflex are not commonly diagnosed in​ school-age children.

The nurse observes a client who is approaching end of life. Which clinical finding correlates with a decreasing blood pressure? A. Rapid heart rate B. Increasing confusion C. Warm, clammy skin D. Decreasing body temperature

B Signs and symptoms of hypotension include​ confusion, cool​ skin, irregular​ pulse, blurry​ vision, and dizziness. Rapid heart​ rate, decreasing body​ temperature, and clammy skin are not indicative of hypotension.

A nurse is caring for a client who is postoperative from an open appendectomy. The client uses an overhead trapeze bar to transfer position in bed. Which type of exercise is demonstrated with this action? A. Isokinetic B. Isotonic C. Isodynamic D. Isometric

B The client who uses an overhead trapeze bar to aid in transfer is demonstrating isotonic activity. Isometric activity is when the joint​ doesn't move but the muscle contracts​ (e.g., wall​ sits). Isokinetic exercise is when the muscle contracts against resistance. There are no exercises called isodynamic.

Which diagnostic test should the nurse review to determine if a client's discomfort is caused by an infection? A. Liver function studies B. White blood cell count C. Hematocrit and hemoglobin D. Urine analysis

B The white blood cell count would be the best study to use to determine if the cause of pain may be due to infection. A urine​ analysis, liver function​ studies, and hematocrit and hemoglobin can provide information about other potential​ issues, but are not the best to determine infection.

A client with gastric cancer receives morphine every 3 hours but is still experiencing pain, despite the last dose 1.5 hours ago. What should the nurse do? A. Provide a gentle massage to help relieve discomfort until the next dose B. Administer a fentanyl lozenge for breakthrough pain per a standing order C. Administer the next dose of morphine a little early D. Return in an hour to administer the next dose of morphine

B Breakthrough pain is a common problem in clients with severe cancer pain. Clients will need a continuous medication for pain in addition to a​ fast-acting medication for breakthrough pain. A massage may not be effective against cancer breakthrough​ pain, and​ it's inappropriate to make the client wait another hour before giving another dose of pain medicine. The nurse should not administer the morphine earlier than it is ordered.

The nurse is monitoring a client who has been using NSAIDs for treatment of chronic back pain for several months. The nurse should instruct the client to take the medicine with food and a full glass of water to address which common side effect? A. Pruritis B. Gastric distress C. Constipation D. Sedation

B Gastric distress is a common side effect of NSAIDS. It can be potentially prevented by taking the medication with food and a full glass of water.​ Pruritus, sedation, and constipation are all side effects of opioids.

A nurse is caring for a newborn with a congenital malformation of the oral soft palate. Which problem will this client be at risk for if the malformation is not repaired? Select all that apply A. Breathing problems because the soft palate includes cilia, which keep foreign bodies out of the trachea B. Swallowing problems because the soft palate includes the uvula, which aids in swallowing C. Swallowing problems because the soft palate rises during swallowing to direct food into the esophagus D. Breathing problems because the soft palate stents the airway open E. Breathing problems because the soft palate closes off the trachea when swallowing

B, C Alterations of the soft palate may lead to swallowing​ problems, increasing the risk of aspiration. This is because the soft palate rises during swallowing to direct food into the esophagus. The soft palate ends at the back of the mouth at a fold called the uvula. The pressure of the bolus against the uvula causes a​ reflex, and the soft palate rises in order to close off the nasopharynx to prevent food from entering into the nasal cavity. Congenital soft palate malformations do not cause problems with the act of external respiration. The soft palate does not contain cilia.

The nurse wants to help with a terminally ill client's discomfort. Which complementary and alternative therapy should the nurse consider for this client? Select all that apply A. Yoga B. Simple touch C. Massage D. Biofeedback E. Acupressure

B, C The interventions of massage and simple touch have been found effective to reduce pain and improve mood in the client nearing the end of life.​ Yoga, biofeedback, and acupressure are not identified as complementary and alternative therapies used during​ end-of-life nursing care.

The nurse is reviewing the chart of an older adult client. Which sensory changes does the nurse anticipate have​ occurred? Select all that​ apply. A. Increased sense of taste B. Impaired sense of smell C. Decreased sense of taste D. Decreased sense of hearing E. Increased tactile sensation

B, C, D The effects of aging on sensory perception include a decreased sense of​ hearing, a decreased sense of​ taste, and an impaired sense of smell. Changes in tactile sensations are not associated with aging.

The nurse is caring for a client who is experiencing discomfort from the nasogastric tube that is necessary for gastric suctioning. What relaxation technique should the nurse teach the client to aid in client comfort? Select all that apply. A. Laughter B. Guided imagery C. Movement techniques D. Muscle relaxation E. Breathing exercises

B, C, D, E (everything but laughter) Relaxation techniques used to aid in client comfort include movement​ techniques, breathing​ exercises, muscle​ relaxation, and guided imagery. Laughter is​ beneficial; however, it promotes psychosocial​ well-being, not relaxation.

The nurse is caring for a client at risk for sensory overload. Which nursing interventions will the nurse implement? Select all that apply. A. Providing books and newspapers B. Providing earphones for the client C. Scheduling clustered care D. Explaining environmental sounds E. Shading the windows

B, C, D, E The interventions the nurse will implement to prevent sensory overload include shading the​ windows, scheduling cluster​ care, explaining environmental​ sounds, and providing earphones for the client. Providing books and newspapers is an intervention for a client experiencing a sensory​ deficit, not sensory overload.

The nurse is preparing to assess a​ client's sensory function. Which neurosensory assessments will the nurse​ include? Select all that​ apply. A. Administering the Romberg test B. Testing kinesthesia C. Distinguishing sharp from dull D. Hot and cold sensation E. Identification of vibration

B, C, D, E The neurosensory assessments included in the assessment of sensory function are testing​ kinesthesia, distinguishing between hot and cold​ sensation, identification of​ vibration, and distinguishing between sharp and dull sensations. The Romberg test is not used to not evaluate sensory perception

The family of an older adult client tells the nurse that they want their mother to remain as active as possible for as long as possible. Which instruction should the nurse provide the​ family? Select all that​ apply. A. Adequate rest and sleep B. Regular exercise C. Good nutritional intake D. Daily stretching E. Adequate calcium intake

B, C, E The best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good​ nutrition, adequate calcium​ intake, and regular exercise. Daily stretching and adequate rest and sleep are not specific strategies to prevent the development of musculoskeletal status disorders.

A client is diagnosed with several fractures of the axial skeleton. Which bone fracture should the nurse anticipate providing care for in this​ client? Select all that​ apply. A. Lower leg B. Vertebra C. Arm D. Ribs E. Femur

B, D The axial skeleton is made up of the​ ribs, sternum, vertebral​ column, and skull. The appendicular skeleton is made up of the pectoral​ girdles, upper​ limbs, pelvic​ girdle, and lower limbs.

The nurse is reviewing the physiology of sensory perception. Which sensory perceptions are associated with internal​ stimuli? Select all that​ apply. A. Visual B. Gustatory C. Olfactory D. Stereognosis E. Visceral

B, D, E The sensory perceptions associated with internal stimuli include gustatory​ (ability to​ taste), visceral​ (stimuli from a large​ organ), and stereognosis​ (the ability to perceive and understand objects through​ touch). Visual data​ (obtained from​ sight) and olfactory data​ (sense of​ smell) are associated with external stimuli.

Which factor influences the expression of pain regardless of culture and is important for the nurse to consider for all clients? Select all that apply A. Underlying health of the client B. Client's skills at reporting pain and discomfort C. Cues from client's family or significant others D. Client's level of trust in the healthcare provider E. Client's ability to cope with pain

B, D, E The​ client's ability to cope with​ pain, skills at reporting pain and​ discomfort, and level of trust in the healthcare provider are important factors to consider for all​ clients, regardless of culture. Underlying health issues and cues from significant others are not vital to understanding how clients express pain.

The nurse is caring for an older adult client that requires a visual aid for reading. Based on the​ client's need, which visual change has the client​ experienced? A. Myopia B. Nearsightedness C. Presbyopia D. Hyperopia

C The older adult client that requires a visual aid for reading is experiencing presbyopia. Presbyopia is an impairment in near vision resulting from a loss of elasticity of the lens related to aging. Myopia is a change in distant vision. Hyperopia is an impairment of near vision in younger people. Nearsightedness is the term used to describe myopia.

A client who is recovering from a spontaneous arm fracture is prescribed a calcium supplement. Which information is most appropriate for the nurse to explain the relationship between calcium and bone​ strength? A. The thyroid gland works to make calcium B. Calcium fills in the spaces caused by the fracture C. The body will break down bone if calcium levels are low D. Calcium helps break down bone tissue

C Bone resorption is the process where the bone is broken down and minerals are released into the bloodstream. Resorption occurs when the minerals are needed for other body functions. When calcium levels are​ low, the parathyroid hormone is released to cause osteoclast action or activity that breaks down bone tissue. The breakdown increases blood calcium levels. If calcium levels in the blood are​ elevated, calcitonin is​ released, which stops osteoclast activity and increases the mineralization of bones. Calcium does not break down bone tissue. The thyroid gland does not make calcium. Calcium does not fill in the spaces caused by the fracture.

The nurse is providing care to a client at a sleep disorder clinic. Which assessment finding does the nurse expect during REM sleep? A. Tachycardia B. Decrease in eye movement C. Decrease in voluntary muscle tone D. Tachypnea

C During REM​ sleep, the nurse would expect the client to have a decrease in voluntary muscle tone. A decrease in heart rate and respiratory rate is also​ expected, not tachycardia or tachypnea. An​ increase, not a​ decrease, in eye movement is expected during REM sleep.

A nurse is caring for a client diagnosed with hypertension. The client's healthcare provider suggests the client begin a regular exercise schedule. The client asks the nurse, "The healthcare provider said that exercise benefits the brain, but I don't see how it can." Which is the correct response by the nurse? A. Exercise increases brain oxygen, resulting in an increase in the number of neurons in the brain B. Exercise increases oxygen flow to the brain, increasing the number of brain cells C. Exercise leads to increased oxygen to the brain, which improves the brain's thinking abilities D. Exercise opens the cerebral arteries which improves short term memory

C Exercise increases ventilation and oxygen​ intake, improving gas​ exchange, eliminating more​ toxins, and increasing oxygen to the​ brain, thus enhancing the​ brain's cognitive​ (thinking) function.​ Short-term memory is not improved with​ exercise, and the number of brain cells and neurons does not increase with exercise and increased oxygen flow.

During a preschool screening the caregiver of a 3 year-old child asks the nurse how many hours of sleep the child requires each night. Which response by the nurse is appropriate? A. A 3 year-old child needs 7 to 9 hours of sleep each night B. A 3 year-old child needs 14 to 17 hours of sleep each night C. A 3 year-old needs 10 to 13 hours of sleep each night D. A 3 year-old child needs 8 to 10 hours of sleep each night

C Growing children require more sleep than adults. The​ 3-year-old child requires 10 to 13 hours of sleep each night. Infants need 14 to 17 hours of sleep in 24 hours. Adolescents require 8 to 10 hours of sleep each night. Adults need 7 to 9 hours of sleep each night.

The nurse is providing care to a client who is approaching the end of life. Which intervention most directly helps to promote psychosocial comfort? A. Reviewing advance directives to ensure end-of-life care desires B. Removing all tubes and medical monitoring devices C. Offering to arrange a visit from a spiritual leader or loved ones D. Providing adequate pain relief with pharmacologic agents

C Offering to arrange a visit by a spiritual leader or loved ones can help to enhance psychosocial comfort.​ Pain-relief medications can help to enhance physical comfort. Reviewing advance directives can help to ensure that​ end-of-life decisions are honored. Removing all tubes and medical devices will not necessarily enhance psychosocial comfort.

A client with altered mobility is unable to bear weight on their wrists. Which type of assistive device should the nurse expect to be prescribed for the​ client? A. Lofstrand crutches B. Axillary crutches C. Platform crutches D. Cane

C Platform crutches are used for clients unable to bear weight on their wrists. When using axillary​ crutches, the body weight is supported by the wrists. Lofstrand crutches use a forearm piece for​ stability, but the weight is still supported by the wrists. A cane is less supportive than​ crutches, and the body weight is still supported on the wrist.

A client with altered mobility reports gastric upset. Which medication should the nurse suspect is causing the​ client's symptoms? A. Bone growth stimulator B. Direct-acting antispasmodic C. Nonsteroidal anti-inflammatory drug (NSAID) D. Skeletal muscle relaxant

C Side effects of nonsteroidal​ anti-inflammatory drugs​ (NSAIDs) include gastric upset and bleeding. Central nervous system​ (CNS) effects are commonly caused by skeletal muscle relaxants. Bone growth stimulators may cause renal or liver impairment.​ Direct-acting antispasmodics may cause​ angina, difficulty​ breathing, and muscle weakness.

A nurse is providing discharge instructions for a client who has been diagnosed with angina. The nurse educates the client on aerobic exercise, as per the healthcare provider's orders. The client asks the nurse, "How will I know when I am working out adequately?" Which is the correct response from the nurse? A. When you are performing aerobic exercise, you shouldn't be able to carry on a conversation B. The goal for aerobic exercise is to maintain target heart rate within 40-55% of maximum heart rate C. When you are performing aerobic exercise, you should be able to carry on a conversation without labored breathing D. The goal for aerobic exercise is to maintain target heart rate within 60-85% of resting heart rate

C The goal for aerobic exercise is to maintain a target heart rate within 60-​85% of the maximum heart​ rate, not 60-​85% of the resting heart rate or 40-​55% of the maximum heart rate.​ However, because heart rates vary among​ individuals, the talk test​ (the ability to carry on a conversation while​ exercising) is being used to replace the target heart rate goal and is the best answer response.

The nurse is caring for an older adult who has experienced a loss of vision. Which will the nurse implement into the plan of​ care? A. Decreasing background noises before communicating B. Using finger spelling as appropriate C. Announcing presence when entering the room D. Speaking at a moderate rate

C The nurse will announce their presence when entering the room as well as identify themselves by name so the client is aware of their presence. Speaking at a moderate​ rate, fingerspelling, and decreasing background noises before communicating are interventions for the hearing impaired.

A new mother who gained 55 pounds during her pregnancy is seen by the nurse-midwife for a 6-week follow-up after her delivery. The mother reports that she has 30 pounds of "baby weight" to lose. The mother tells the nurse that she is having trouble sleeping and asks why this is occurring because her infant is now sleeping through the night. Which response by the nurse is the most appropriate? A. Once you become a parent, you have to get used to sleepless nights B. Hormonal shifts are causing insomnia. I will prescribe you a sedative C. Your lack of weight loss may be the problem. Let's discuss a plan for this D. You must be worried about the baby's health. I will refer you to a counselor

C Weight gain has been associated with reduced total sleep​ time, interrupted​ sleep, and earlier awakening. It is appropriate for the nurse and the midwife to discuss a plan for this new mother to lose weight. Hormonal shifts can cause alterations in sleep​ patterns/insomnia in a new mother 6 weeks postpartum.​ Sedation, however, is not the appropriate treatment. There is no evidence to support that the client is worried about her​ baby's health. Becoming a parent does not automatically cause sleep disturbances.

A nurse is caring for an older adult in the hospital and is providing the client with instruction on proper oral care. Which instructions will the nurse include in the teaching? A. Use an alcohol-based mouth rinse after brushing B. Use a circular technique when brushing C. Use plain water to rinse the mouth after meals D. Use mineral oil as a lip moisturizer if needed

C When teaching the older adult about oral​ care, the nurse should instruct the client to rinse the mouth with plain water after meals to help remove residual food debris. Circular brushing techniques are not recommended. Use of mineral oil as a lip moisturizer is not recommended because aspiration of this may cause pneumonia.​ Alcohol-based mouth rinses are not recommended because these can irritate oral tissues.

The nurse admitted a client suspected of having nerve problems. Which diagnostic test should the nurse expect the​ client's healthcare provider to​ order? Select all that​ apply. A. Peripheral bone density B. Dual-energy x-ray absorptiometry C. Electromyography D. Dual-photon absorptiometry E. Nerve conduction studies

C, E Electrical studies are used to determine electrical activity of the muscles or identify nerve compression and include electromyography and nerve conduction studies. Diagnostic tests that produce an image include peripheral bone​ density, dual-photon​ absorptiometry, and​ dual-energy x-ray absorptiometry.

The nurse notices that a client who is dying is refusing to visit with family. What should the nurse consider this client is demonstrating? A. Unresolved family problems B. Major depression C. Dysfunctional grieving D. Anticipatory grief

D Anticipatory grief can result in a dying person distancing themselves from family or friends in an attempt to minimize the pain of loss. This is not a sign of unresolved family​ problems, dysfunctional​ grieving, or major depression.

A terminally ill client has a dry mouth and refuses to take any food or fluids by mouth. Which intervention should the nurse implement for this client? A. Place a nasogastric tube to administer artificial feeding B. Feed the client ice chips or popsicles C. Administer intravenous fluids to maintain hydration level D. Apply moist sponges to the mouth and lips

D Application of moist sponges to the mouth and lips can help relieve dry mouth in clients who are refusing to eat or drink. Administration of intravenous fluids or a nasogastric tube may be possible interventions but require an order from the healthcare provider and may be refused by the client or the healthcare proxy. Attempting to feed the client ice chips or popsicles after refusal of taking in other foods or liquids is insensitive to the wishes of the client.

A client with a terminal illness does not want to receive cardiopulmonary resuscitation. Which medical order should the nurse expect to be written for this client? A. Do-not-intubate (DNI) B. Involuntary euthanasia C. Voluntary euthanasia D. Do-not-resuscitate (DNR)

D A​ do-not-resuscitate order​ (DNR) is a medical order that states the​ client's wishes to withhold cardiopulmonary resuscitation​ (CPR) in the event of respiratory or cardiac arrest. A​ do-not-intubate order​ (DNI) prohibits endotracheal intubation in the event of severe respiratory failure or respiratory arrest. Voluntary euthanasia occurs when the client or the​ client's family gives consent for the actions that will result in death for the client. Involuntary euthanasia is defined as euthanasia performed against the wishes of the client or the​ client's family.

During a​ well-child visit, a female high school student complains about their inability to do as much physically as their twin brother. Which response by the nurse is​ accurate? A. Muscle growth in girls peaks at age 13 B. Girls have less muscle after the age of 16 C. Girls need to eat more to have more muscle D. Boys have more muscle mass than girls

D Boys have more muscle mass than girls. Muscle growth in girls peaks between the ages of 16 and 20. Eating more will not increase the amount of muscle. Boys and girls have the same amount of muscle until age 13.

Which type of exercise is also known as dynamic exercise? A. Isometric B. Isokinetic C. Isodynamic D. Isotonic

D Isotonic exercises are also known as dynamic exercises. These exercises are said to be practiced when active movement occurs and muscles shorten and contract. There are no exercises called isodynamic. Isometric exercises are also known as static exercises because the muscle contracts but the joint does not move. Isokinetic exercises are known as​ resistive, where the muscle contracts against resistance.

While completing an assessment after administration of morphine for acute pain the nurse notes that the client's respiratory rate is 10 and that the client is very lethargic. Which should the nurse do first in response to these assessment findings? A. Immediately obtain a complete set of vital signs to establish a baseline B. Continue to monitor for any further decrease in respirations or change in level of consciousness C. Contact the healthcare provider immediately to advise of client changes D. Administer naloxone as prescribed in incremental doses until symptoms of overdose are resolved.

D Morphine can cause respiratory depression. If this​ occurs, naloxone should be immediately administered as prescribed in incremental doses until the overdose is resolved. A baseline set of vital signs should be obtained as soon as possible but vital signs are not the first priority. Once naloxone is​ begun, the healthcare provider should be contacted. The nurse would not just continue to monitor for further changes as this could result in death.

A nurse is caring for an older adult who complains of dry mouth. The client states "food just doesn't taste the same anymore." The nurse understands that the client's dry mouth may be the cause of the client's altered taste. Which statement is true regarding saliva and taste? A. Because saliva is produced in the tongue, a decrease in saliva will decrease taste B. A decrease in saliva will decrease taste because saliva mechanically breaks down food into smaller parts C. Saliva increases taste by increasing the function of the taste buds, so a decrease in saliva will decrease taste D. Decreased saliva production thins the oral mucosa and contributes to dry mouth, so a decrease in saliva will decrease taste

D Saliva moistens food and provides enzymes to digest starches. As saliva​ decreases, it contributes to thinning of the oral​ mucosa, contributing to dry mouth and altered taste. Saliva does not increase the function of the taste buds. Saliva is produced by the salivary​ glands, not the tongue. Saliva chemically breaks down​ food; teeth mechanically break down food.

A caregiver of a 10 year-old fifth grader reports to the nurse about the current behavior of the child. The teacher reported to the caregiver that the student is falling asleep in class, is distracted in interactions with the peer group, and has trouble concentrating, leading to poor grades on assignments. The caregiver also reports that the child often plays video games late into the night. Which issue does the nurse suspect as the cause of the behavior? A. Sundown syndrome B. Nocturnal emissions C. Waking up frequently at night due to nightmares D. Screen time at night

D School-age children need 10-11 hours of sleep per night. They may spend more time at the​ computer, playing video​ games, and watching​ TV, leading to difficulty falling asleep and fewer hours of sleep. A regular and consistent sleep schedule and bedtime routine need to be established. The client is not experiencing sundown syndrome. Nocturnal emissions and nightmares are not the cause of the​ client's symptoms.

The nurse is caring for a visually impaired client who will be utilizing a service dog. Which statement most accurately describes the​ nurse's understanding of service​ dogs? A. Service dogs can be easily obtained for the visually impaired B. Another family member will need to care for the service dog C. The cost of training a service dog is inexpensive D. The service dog can assist with activities of daily living

D Service dogs protect individuals with sensory impairments from risk and assist them with activities of daily living​ (ADLs), such as opening doors and fetching objects. The cost of training a service dog is​ expensive, service dogs are not easily​ obtained, and another family member does not need to care for them.

The nurse enters the room of a sleeping client whose eyes are rolling from side to side and whose respiratory rate and heart rate have decreased. The client is easily aroused and​ states, "I​ wasn't asleep." Which state of​ non-REM (NREM) sleep was the client​ in? A. Stage N4 B. Stage N3 C. Stage N2 D. Stage N1

D Stage N1 is the stage of light sleep in which the client is easily​ aroused, the respiratory rate and heart rate decrease​ slightly, and the eyes roll slowly from side to side. Stage N2 is the stage of light sleep in which body processes slow down and the eyes are still. Stage N3 is the stage of deep sleep in which it is difficult to arouse the​ client, muscles are​ relaxed, and reflexes are diminished. Stage N4 is the stage of deep sleep that differs from Stage N3 in the number of delta waves produced.

The nurse is admitting a client for the treatment of​ closed-angle glaucoma. Which procedure should the nurse anticipate will be​ performed? A. Laser surgery B. Lens implantation C. Photodynamic therapy D. Laser iridotomy

D The nurse can anticipate a laser iridotomy to be performed to treat the​ client's closed-angle glaucoma. Laser surgery and photodynamic therapy are used to treat​ age-related macular degeneration. Lens implantation is used to treat cataracts.

The adult daughter of a client who is nearing death questions the quality of care being provided to the client. What should the nurse do to support the daughter's needs during the dying process? A. Suggest that the daughter go home to get some rest B. Permit the daughter to spend uninterrupted time with the client C. Ask the healthcare provider to talk with the daughter D. Respond to the daughter's concerns

D The nurse needs to support the family through the grieving process. To do​ this, the nurse should respond to the​ daughter's concerns. Suggesting that the daughter go home to get some rest does not address the​ daughter's concerns about quality of care. The nurse can talk to the daughter about the quality of care and does not need to contact the healthcare provider. Permitting the daughter to spend uninterrupted time with the client might exacerbate the feeling that care is less than optimal.

The nurse is reviewing the chart of a client diagnosed with strabismus. Which most accurately describes the​ nurse's understanding of the​ diagnosis? A. Pupils' inability to constrict B. Eyes turned inward toward each other C. Change in distant vision D. Misalignment of the eyes

D The nurse understands that the diagnosis of strabismus is a misalignment of the eyes. Myopia is a change in distant vision. The​ pupil's inability to constrict reflects a failure to accommodate. Eyes that can turn in toward each other is a normal finding termed convergence.

The nurse is preparing to examine the ears of a​ 2-year-old child. Which intervention should the nurse implement prior to the​ assessment? A. Remove the cerumen prior to examination with the otoscope B. Pull the auricle up and back C. Allow the child to play with the otoscope D. Have the parent help hold the child's head against their chest

D The nurse will have the parent help hold the young​ child's head against their chest to prevent movement. The auricle of a child over 3 years of age will be pulled up and back prior to​ assessment; for a child under 3 years of​ age, the auricle will be pulled down and back. An older child may be allowed to play with the equipment prior to the assessment. Cerumen is not removed prior to the examination with an otoscope.

A nurse in a primary care clinic is caring for a client who has osteoporosis but no significant health history. Which statement made by the nurse is most appropriate when teaching this client? A. Isometric exercise is an excellent choice for your condition B. Non-weight-bearing exercise is most beneficial in your condition C. Swimming is most beneficial for your condition D. Walking is an excellent choice of exercise for your condition

D ​Walking, or​ weight-bearing exercise, is most beneficial for the client with osteoporosis who can bear weight. Bone density and strength are maintained through​ weight-bearing activities. The stress of​ weight-bearing and​ high-impact movement maintains a balance between osteoblasts​ (bone-building cells) and osteoclasts​ (bone-resorption and​ bone-breakdown cells). Although swimming is a great choice for those who cannot bear​ weight, this client would best benefit from walking. Isometric exercises are beneficial for muscles but do not provide​ weight-bearing benefits for the client with osteoporosis.

The nurse is providing education to the client on the effect of lifestyle factors on sleep. Which should the nurse include as a factor that negatively influences sleep? Select all that apply A. Morning exercise B. Relaxation C. Regular nighttime schedule D. Irregular work schedule E. Evening exercise

D, E Factors that negatively impact sleep include evening exercise and an irregular work schedule. Morning​ exercise, relaxation, and regular nighttime schedule are known to enhance sleep.