Health and Physical Assessment

Which pulse site is used to perform Allen's test? 1. Ulnar 2. Brachial 3. Femoral 4. Dorsalis pedis

1. Ulnar The ulnar pulse site is used to perform Allen's test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions? 1. "You do not need to wear them while you are awake, but it is important to wear them at night." 2. "You will need to apply them in the morning before you lower your legs from the bed to the floor." 3. "If they bother you, you can roll them down to your knees while you are resting or sitting down." 4. "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

2. "You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? 1. NANDA-I label, related factor, and etiologies 2. NANDA-I label, risk factor, and nursing interventions 3. NANDA-I label, related factor, and nursing interventions 4. NANDA-I label, related factor, and defining characteristics

4. NANDA-I label, related factor, and defining characteristics The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining characteristics. This format is also known as the problem, etiology, and symptoms (PES) format. The nurse does not document the nursing diagnosis as NANDA-I label, related factor, and etiologies. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse does not document the nursing diagnosis as NANDA-I label, risk factor, and nursing interventions. A risk for nursing diagnosis uses the risk factor instead of related factor. Nursing interventions are not included in a nursing diagnosis. Therefore, the nurse does not document the nursing diagnosis as NANDA-I label, related factor, nursing interventions.

The nurse at a community healthcare center focuses on providing primary preventive care. What is the focus of primary preventive care? 1. Rehabilitating the client 2. Treating early stages of disease 3. Preventing complications from illness 4. Promoting health in healthy individuals

Promoting health in healthy individuals Primary prevention precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Health education programs, immunizations, and physical and nutritional fitness activities are primary prevention activities. Tertiary preventive care occurs when an individual has a permanent or irreversible disability. The client undergoing rehabilitation is receiving tertiary preventive care. Secondary preventive care focuses on individuals who are experiencing health problems. Secondary preventive care involves treating clients in the early stages of disease. It also focuses on preventing complications from illness.

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation? 1. 1+ 2. 2+ 3. 3+ 4. 4+

1. +1 A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? 1. Blended family 2. Extended family 3. Alternative family 4. Single-parent family

1. Blended family The child belongs to a blended family. Such a family is formed when parents bring unrelated children from prior relationships into a new, joint living situation. Extended family comprises the husband, wife, children, uncles, aunts, cousins, and grandparents. An alternative family may have grandparents caring for grandchildren. It may also be a multi-adult household with cohabiting partners or homosexual couples. A single-parent family is formed when one parent cares for the children following the death, divorce, or desertion of the other parent. A single person may also decide to have or adopt a child.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? 1. Bruit 2. Ectropion 3. Entropion 4. Borborygmi

1. Bruit A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outwards away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? 1. Data collection 2. Data validation 3. Data clustering 4. Data interpretation

1. Data collection The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. What is the muscle functionality of the client? 1. Full range of motion with gravity 2. Full range of motion with gravity eliminated 3. Full range of motion against gravity with full resistance 4. Full range of motion against gravity with some resistance

1. Full range of motion with gravity In the Lovett scale, grade F (fair) is given to clients who exhibit a full range of motion with gravity. Full range of motion in passive motion is assigned a P (poor) score. When a client exhibits full range of motion against gravity with full resistance, the client is given an N (normal) score. When a client exhibits full range of motion against gravity with marginal resistance, the client is given a score of G (good).

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? 1. Heat stroke 2. Heat exhaustion 3. Accidental hypothermia 4. Malignant hyperthermia

1. Heat stroke Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply. 1. Loss of turgor 2. Urinary incontinence 3. Decreased night vision 4. Decreased mobility of ribs 5. Increased sensitivity to odors

1. Loss of turgor 3. Decreased night vision 4. Decreased mobility of ribs In older adults, the skin loses its turgor or elasticity and there is fat loss in the extremities. Visual acuity declines with age; therefore, decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, diminished sensitivity to odor, not increased sensitivity, is often found.

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action? 1. Perform an assessment of the client before resuming the change-of-shift report. 2. Continue the change-of-shift report and include the decrease in blood pressure. 3. Lower the diastolic pressure limits on the monitor during the change-of-shift report. 4. Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.

1. Perform an assessment of the client before resuming the change-of-shift report. The cause of the alarm should be investigated and appropriate intervention instituted; after the client's needs are met, then other tasks can be performed. An alarm should never be ignored; the client's status takes priority over the change-of-shift report. The diastolic pressure limit has been prescribed by the primary healthcare provider and should not be changed for the convenience of the nurse. Alarms always should remain on; the alarm indicates that the client's blood pressure has decreased and immediate assessment is required.

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. 1. Ptosis and blurred vision 2. Agitation and hyperactivity 3. Confusion and disorientation 4. Increased sensitivity to pain 5. Decreased auditory alertness

1. Ptosis and blurred vision 5. Decreased auditory alertness Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema? 1. Shift of fluid into the interstitial spaces 2. Weakening of the cell wall 3. Increased intravascular compliance 4. Increased intracellular fluid volume

1. Shift of fluid into the interstitial spaces Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathologic reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.

What is the correct order of phases a client experiences in the event of a change in body image following an illness? 1. Shock 2. Withdrawal 3. Acknowledgement 4. Acceptance 5. Rehabilitation

1. Shock 2. Withdrawal 3. Acknowledgement 4. Acceptance 5. Rehabilitation When a client experiences a change in body image, the client adjusts to the condition in five phases. The initial reaction is that of shock. The client is in shock and tries to depersonalize it by discussing it as happening to someone else. As the client and family begin to recognize the reality of the change, they enter the withdrawal phase. They become anxious and refuse to discuss the subject. Then the client enters the acknowledgment phase. The client and family begin to acknowledge the condition and move through a period of grieving. By the end of the acknowledgement phase, they are ready to accept the loss and move into the acceptance phase. They realize the need for rehabilitation. During the rehabilitation phase, the client is ready to learn to use prosthesis, or change lifestyles or goals.

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? 1. Visceral pain 2. Somatic pain 3. Referred pain 4. Intractable pain

1. Visceral pain Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.

Which degree of edema will result in a 6-mm deep indentation upon pressure application? 1. 4+ 2. 3+ 3. 2+ 4. 1+

2. 3+ The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

Which factor can elevate the oxygen saturation during an assessment? 1. Nail polishes 2. Carbon monoxide 3. Intravascular dyes 4. Skin pigmentation

2. Carbon monoxide Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

The nurse is gathering a client's health history. Which information does should the nurse classify as biographical information? Select all that apply. 1. Symptoms 2. Client's age 3. Family Structure 4. Type of insurance 5. Occupation status

2. Client's age 4. Type of insurance 5. Occupation status Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client? 1. Fair (F) 2. Good (G) 3. Trace (T) 4. Normal (N)

2. Good (G) According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

Which statement best describes a diagnostic label? 1. It is a condition that responds to nursing interventions. 2. It describes the essence of the client's response to health conditions. 3. It describes the characteristics of the client's response to health conditions. 4. It is identified from the client's assessment data and associated with the diagnosis.

2. It describes the essence of the client's response to health conditions. A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties? 1. Sims position 2. Prone position 3. Supine position 4. Knee-chest position

2. Prone position Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion? 1. The client's temperature returns to an acceptable value at least once in the past 24 hours 2. The client's fever spikes and falls without a return to normal temperature levels 3. Periods of febrile episodes and periods with acceptable temperature values occur 4. The client has a constant body temperature continuously above 38°C with minimal fluctuation

2. The client's fever spikes and falls without a return to normal temperature levels In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern. Periods of febrile episodes and periods with acceptable temperature values is a relapsing type of fever. In a sustained fever, the body temperature is constantly above 38°C and has little fluctuation.

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? 1. The client weighs 151 lbs (68.5 Kg). 2. The client's pain is 7 on a scale of 1 to 10. 3. The client's fasting blood sugar is 95 mg/dL. 4. The client's blood pressure is 140/90 mm/Hg.

2. The client's pain is 7 on a scale of 1 to 10. Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client's health status. The client's weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? 1. "You will need to ask your healthcare provider; it is not part of the usual tests for people your age." 2. "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3. "It is performed routinely starting at your age as part of an assessment for colon cancer." 4. "There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

3. "It is performed routinely starting at your age as part of an assessment for colon cancer." The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? 1. "I would, but my back hurts today." 2. "Okay. It will be my good deed for the day." 3. "Of course. I want to do whatever I can for you." 4. "I would like to, but it is not in my job description."

3. "Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description.

A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be most motivated to learn? 1. A 55-year-old client who had a mastectomy and is very anxious about her body image 2. An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking 3. A 56-year-old client who had a heart attack last week and is requesting information about exercise 4. A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

3. A 56-year-old client who had a heart attack last week and is requesting information about exercise A client who is requesting information is indicating a readiness to learn. When a nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse should encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find? 1. Large area of petechiae 2. Red birthmark that has recently become lighter in color 3. Brown or black mole with red, white, or blue areas 4. Patchy loss of skin pigmentation

3. Brown or black mole with red, white, or blue areas Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades over time. A patchy loss of skin pigmentation indicates vitiligo.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1. Increase fluid intake. 2. Restrict fluids. 3. Encourage early mobility. 4. Elevate the knee gatch of the bed.

3. Encourage early mobility. In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk for thrombophlebitis.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? 1. Increased skin elasticity and an increase in testosterone production 2. Impaired fat digestion and an increase in pepsin production 3. Increased blood pressure and decreased cardiac output 4. An increase in body warmth and some swallowing difficulties

3. Increased blood pressure and decreased cardiac output With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. Changes in libido may occur. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in subcutaneous fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse drug reactions.

Which term refers to the exaggeration of the posterior curvature of the thoracic spine? 1. Lordosis 2. Scoliosis 3. Kyphosis 4. Osteoporosis

3. Kyphosis Kyphosis is an excessive outward curvature of the spine that causes hunching of the back. Lordosis is the excessive inward curvature of the lumbar part of the spine. Scoliosis is the abnormal lateral curvature of the spine. Osteoporosis is characterized by a loss of bone mass and a deterioration of bone tissues.

Which site is best used to inspect a client who is suspected to have jaundice? 1. Skin 2. Palm 3. Sclera 4. Conjunctiva

3. Sclera The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

When teaching about aging, the nurse explains that older adults usually have what characteristic? 1. Inflexible attitudes 2. Periods of confusion 3. Slower reaction times 4. Some senile dementia

3. Slower reaction times A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? 1. Increase fluids. 2. Increase fiber in the diet. 3. Wash hands with soap and water. 4. Wash hands with an alcohol-based hand sanitizer.

3. Wash hands with soap and water. Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.

An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? 1. 36.0ºC 2. 36.8ºC 3. 37.2ºC 4. 38.5ºC

4. 38.5ºC In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition? 1. 1+ 2. 2+ 3. 3+ 4. 4+

4. 4+ Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of what? 1. A food allergy 2. Noncompliance with medications 3. Side effects from medications 4. A nutritional deficiency

4. A nutritional deficiency All of the signs listed are classic for a poor nutritional state lacking in basic nutrients such as vitamins and protein. A specific food allergy or medication is not described; therefore there is not enough information to assume the signs and symptoms are related to either or to noncompliance with medications.

Which physical assessment technique involves listening to the sounds of the body? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

4. Auscultation Auscultation involves listening to the sounds of the body. Palpation involves using the sense of touch to assess and collect data. An inspection involves the nurse carefully looking to collect data. Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs.

Which concept refers to respecting the rights of others? 1. Maturity 2. Systematicity 3. Inquisitiveness 4. Open-mindedness

4. Open-mindedness Open-mindedness refers to respecting the rights of others and being tolerant of different viewpoints. Maturity refers to reflecting on one's own judgments and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising five days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing? 1. Action 2. Preparation 3. Maintenance 4. Precontemplation

4. Precontemplation The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to six months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins six months after the change has started and continues indefinitely.

The home healthcare nurse visits a client who has two grandchildren living in the household. The client's adult child is a single-parent who is in prison serving a 15-year sentence. The children accompany the grandparent on 2-hour contact visits on weekends as often as possible. Which term does the nurse use to define this family form? 1. Nuclear family 2. Extended family 3. Single-parent family 4. Skip-generation family

4. Skip-generation family A skip-generation family form is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, incarcerated parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of two parents and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, incarceration, or desertion. It may also occur when a single person decides to have or adopt a child.