Health Promotion and Maintenance
A primiparous client planning to breast-feed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth breasts begin to fill with milk within which of the following periods? a) 12 hours. b) 24 hours. c) 7 days. d) 2 to 4 days.
2 to 4 days.
A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? a) Middle area b) Temporal area c) Behind the ears d) Top of the head
Behind the ears
A young woman would like to lower her risk of developing cancer and is following a low-fat diet. Which type of cancer is not associated with excess dietary fat intake? a) Breast cancer. b) Rectal cancer. c) Colon cancer. d) Prostate cancer
Breast cancer.
Values are known to affect a person's functional health. Which of the following values may be related to the perception of health? Select all that apply. a) Responsibility. b) Intuition. c) Language. d) Cooperation. e) Discipline.
• Responsibility. • Discipline. • Cooperation.
vA 4-year-old girl has a urinary tract infection (UTI). Which statement by the mother demonstrates understanding of preventing future UTIs? a) "When she starts urinating frequently, I should call the physician to request antibiotics." b) "I should help my child learn to wipe her bottom from back to front." c) "I will let her take a warm bath for 15 minutes each day." d) "I shouldn't let my daughter take bubble baths."
"I shouldn't let my daughter take bubble baths."
The nurse is preparing to administer the measles-mumps-rubella (MMR) and varicella vaccines to an infant who has an egg and wheat allergy. Which of the following is the appropriate action by the nurse? a) Administering both vaccines b) Administering neither vaccine c) Administering only the MMR vaccine d) Administering only the varicella vaccine
Administering only the MMR vaccine
Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first: a) Obtain an order for an intramuscular antiemetic medication. b) Assess the client's cervical dilation and station. c) Warm the temperature of the room by a few degrees. d) Increase the rate of intravenous fluid administration.
Assess the client's cervical dilation and station
When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan? a) Cardiac output increases by 25% to 50% during pregnancy. b) The anterior pituitary gland secretes oxytocin late in pregnancy. c) The temperature decreases slightly early in pregnancy. d) The circulating fibrinogen level decreases as much as 50% during pregnancy.
Cardiac output increases by 25% to 50% during pregnancy.
The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which of the following instructions should the nurse give to the mother? a) Contact the primary health care provider if the weight loss continues over the next few days. b) Switch to a soy-based formula because the current one seems inadequate. c) Change to a higher-calorie formula to prevent further weight loss. d) Continue feeding every 3 to 4 hours since the weight loss is normal.
Continue feeding every 3 to 4 hours since the weight loss is normal.
vWhich of the following statements indicates that a client understands the need for routine screening to detect colorectal cancer? a) "I need to have a barium enema after age 20." b) "I need to have a carcinoembryonic antigen (CEA) test after age 50." c) "I need to have an annual digital examination after age 40." d) "I need to have a proctosigmoidoscopy after age 30."
"I need to have an annual digital examination after age 40."
A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority? a) Maintain normal respirations. b) Maintain body temperature. c) Decrease venous congestion. d) Prevent injury to lower extremities.
Decrease venous congestion.
To assess a 9-year-old's social development, the nurse asks the parent if the child: a) Has a best friend. b) Enjoys active play. c) Thinks independently. d) Is able to organize and plan.
Has a best friend
A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding? a) It's normal and requires no action. b) It calls for a biopsy as soon as possible. c) It calls for a repeat Pap test in 6 weeks. d) It calls for a repeat Pap test in 3 months.
It calls for a biopsy as soon as possible
A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage? a) Placenta previa b) Uterine infection c) Hypertension d) Severe pain
Placenta previa
The nurse in the emergency department is caring for a 3-year-old child with a fractured humerus. The child is crying and screaming, "I hate you." Which of the following would be appropriate? a) Tell the parents they will need to wait out in the lobby. b) Reassure the parents that this a normal behavior under the circumstances. c) Ask the charge nurse to assign this client to another nurse. d) Ask the parents to discipline the child so that the physician can treat her.
Reassure the parents that this a normal behavior under the circumstances.
Which of the following changes are associated with normal aging? a) Collagen becomes elastic and strong. b) The dermis becomes highly vascular and assists in the regulation of body temperature. c) Subcutaneous fat and extracellular water decrease. d) The outer layer of skin is replaced with new cells every 3 days.
Subcutaneous fat and extracellular water decrease.
lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply. a) Potatoes b) Pizza c) Corn d) Bagels e) Apples
a) Potatoes c) Corn e) Apples
A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: a) "Do you have any birds at home?" b) "Do you have any cats at home?" c) "Have you ever had osteomyelitis?" d) "Have you recently had a rubeola vaccination?"
"Do you have any cats at home?"
A parent of a toddler brings the child to the emergency room because the child has accidentally been scalded by hot water spilling from the stove. In order to differentiate the burn from potential abuse, the nurse first should assess the child: a) For a circular or glove pattern. b) On the front of the body. c) On the back of the body. d) On the buttocks
On the front of the body.
The nurse is providing teaching to the parents of a young child with a urinary tract infection. The nurse's goal is to help the parents understand their role in the treatment of the infection. Which statement by the parents lets the nurse know that the teaching has been successful? a) "We need to come to the emergency department for IV fluids." b) "We need to administer the oral antibiotics as prescribed." c) "We need to encourage cranberry juice to treat the infection." d) "We can treat the infection by increasing oral fluid intake."
"We need to administer the oral antibiotics as prescribed."
A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which emotional response is typical during early adolescence? a) Moodiness b) Combativeness c) Cooperativeness d) Frequent anger
Moodiness
While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated and the presenting part is at 0 station. Which of the following should the nurse do first? a) Prepare the client for imminent birth. b) Note the color, amount, and odor of the amniotic fluid. c) Auscultate the client's blood pressure. d) Perform a vaginal examination to determine dilation.
Note the color, amount, and odor of the amniotic fluid.
A group has asked the nurse to discuss how lifestyle factors affect heart health. Which of the following statements by members of the group would indicate that the teaching was effective? Select all that apply. a) "Gradually increasing my exercise levels will help enhance circulation through the heart." b) "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." c) "Walking is excellent exercise to strengthen my heart." d) "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." e) "Chewing tobacco rather than smoking it lessens the negative effect on the heart."
• "Gradually increasing my exercise levels will help enhance circulation through the heart." • "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." • "Walking is excellent exercise to strengthen my heart." • "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels."
The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which vaccine order would the nurse question? a) Haemophilus influenzae type B (Hib). b) Diphtheria, tetanus, and acellular pertussis (DTaP). c) Hepatitis B (Hep B). d) Measles, mumps, and rubella (MMR).
Measles, mumps, and rubella (MMR).
A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? a) "Babies can't digest solid food properly until they're 3 or 4 months old." b) "The baby is gaining weight and doing well. There is no need for solid food yet." c) "Things have changed a lot since your children were born." d) "Introducing solid food early leads to eating disorders later in life."
"Babies can't digest solid food properly until they're 3 or 4 months old."
Which of the following assessment questions is most likely to yield clinically meaningful data about a female client's sexual identity? a) "Do you find that your health allows you to enjoy a meaningful sex life?" b) "Are you satisfied with the quality of your relationships right now?" c) "How do you feel about yourself as a woman?" d) "Have you ever had any sexually transmitted diseases in the past?"
"How do you feel about yourself as a woman?"
A client with allergic rhinitis asks the nurse what to do to decrease the rhinorrhea. Which of the following instructions would be appropriate for the nurse to give the client? a) "It is important to increase your activity. A daily brisk walk will help promote drainage." b) "Ask the doctor for antibiotics. Antibiotics will help decrease the secretion." c) "Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks." d) "Use your nasal decongestant spray regularly to help clear your nasal passages."
"Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks."
A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every: a) 15 g of carbohydrates. b) 20 g of carbohydrates. c) 25 g of carbohydrates. d) 10 g of carbohydrates.
15 g of carbohydrates
nurse is teaching the parents of a 6-month-old infant about usual growth and development. Which statements about infant development are true? Select all that apply. a) Head lag is commonly noted in infants at age 6 months. b) Stranger anxiety usually peaks at 12 to 18 months. c) A 6-month-old infant has difficulty holding objects. d) A teething ring is appropriate for a 6-month-old infant. e) Lack of visual coordination usually resolves by age 6 months. f) A 6-month-old infant can usually roll from prone to supine and supine to prone positions
d) A teething ring is appropriate for a 6-month-old infant. e) Lack of visual coordination usually resolves by age 6 months. f) A 6-month-old infant can usually roll from prone to supine and supine to prone positions.
The nurse should teach the client with viral hepatitis to: a) Intensify routine exercise and increase strength. b) Avoid contact with others and live separately. c) Limit caloric intake and reduce weight. d) Increase carbohydrates and protein in the diet.
Increase carbohydrates and protein in the diet.
According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? a) Identity versus role confusion b) Industry versus inferiority c) Initiative versus guilt d) Trust versus mistrust
Industry versus inferiority
Which of the following children should be referred for further assessment regarding language development? a) A 2-year-old who has a vocabulary of 100 words and can point to objects. b) A 3-year-old who has a vocabulary of 900 words and can make a complete sentence of three or four words. c) A 2-year-old who has a vocabulary of 300 words and can combine two or three words in a phrase. d) A 1-year-old who has a vocabulary of 8 words and can say "mommy" and "daddy" with specific reference to the correct person.
A 2-year-old who has a vocabulary of 100 words and can point to objects.
The mother says that the infant's primary care provider recommends certain foods, but the infant refuses to eat them after breast-feeding. The nurse should suggest that the mother alter the feeding plan by doing which of the following? a) Offering breast milk as long as the infant refuses to eat solid foods. b) Allowing the infant to nurse for a few minutes and then offering solid foods. c) Mixing pureed food with some breast milk in a bottle with a large-holed nipple. d) Offering dessert followed by some vegetables and meat.
Allowing the infant to nurse for a few minutes and then offering solid foods.
A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? a) Uterine enlargement b) Presence of menses c) Fetal heart tones d) Breast sensitivity
Breast sensitivity
A primiparous woman has recently given birth to a term infant. Priority teaching for the patient includes information on: a) Breastfeeding b) Infant bathing c) Sudden infant death syndrome (SIDS) d) Infant sleep-wake cycles
Breastfeeding
A nulliparous client tells the nurse that during her last pelvic examination the physician said that her uterus was in a severe retroverted position. The nurse determines that the client may experience which of the following? a) Frequent vaginal infections. b) Difficulty conceiving a child. c) Pain from endometriosis. d) Severe menstrual cramping.
Difficulty conceiving a child
At which of the following times should the nurse anticipate assisting a client to breast-feed her neonate? a) In about 4 hours, after the baby has had some sleep. b) In about 2 hours, after the baby has been evaluated. c) After the neonate's first period of reactivity. d) During the neonate's first period of reactivity.
During the neonate's first period of reactivity.
The absence of which of the following behaviors in an 18-month-old child would cause the nurse to be concerned? a) Copying a circle. b) Playing with pull toys. c) Building a tower of eight blocks. d) Playing tag with other children.
Playing with pull toys.
A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications? a) Fat embolus. b) Air embolus. c) Thrombophlebitis. d) Stress fractures.
Thrombophlebitis
A nurse is educating a client who is at risk for coronary artery disease (CAD). The nurse knows that the client needs more education when he states that the risk factors that can be controlled or modified include: a) inactivity, stress, gender, and smoking. b) gender, family history, and older age. c) obesity, inactivity, diet, and smoking. d) stress, family history, and obesity
gender, family history, and older age
A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions? a) Papules b) Vesicles c) Plaque d) Pustules
Vesicles
The most common cause of megaloblastic, macrocytic anemias is: a) Chronic disease. b) Folate or vitamin B12 deficiency. c) Iron deficiency. d) Infection.
Folate or vitamin B12 deficiency.
A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following? a) Grief over the ending of the pregnancy. b) Indication of postpartum "blues." c) Disappointment in the baby's gender. d) A normal response to the birth.
A normal response to the birth.
A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant? a) Altered role performance related to new responsibilities within the family b) Knowledge deficit related to normal infant growth and development c) Altered nutrition (less than body requirements) related to difficulty sucking d) Parental sleep pattern disturbance related to the baby's feeding schedule
Altered nutrition (less than body requirements) related to difficulty sucking
A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate? a) Making the child feel ashamed for not cooperating b) Showing trust in the child's ability to cooperate even with an unpleasant procedure c) Explaining the medication's effects in detail to ensure cooperation d) Mixing the medication in milk so the child isn't aware that it's there
Showing trust in the child's ability to cooperate even with an unpleasant procedure
A client, now 37 weeks pregnant, calls the clinic because she is concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to the client's concerns, the nurse should take which action? a) Make an appointment because the client needs to be evaluated. b) Arrange for the client to be admitted to the birth center and prepare for birth. c) Tell the client to go to the hospital; she may be experiencing signs of heart failure. d) Explain that these are expected problems for the latter stages of pregnancy.
Explain that these are expected problems for the latter stages of pregnancy.
The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks only Spanish and gave birth to a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client's intake of which of the following? a) Tomatoes. b) Meat products. c) Corn products. d) Potatoes
Meat products
A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because: a) they contain high levels of phenylalanine. b) they are not well tolerated in children with PKU until after age 2. c) they contain high levels of phenylketones, which inhibit muscle growth. d) they are difficult for clients with PKU to digest.
they contain high levels of phenylalanine.
Which desired outcome demonstrates effective parent teaching about disciplining a toddler? a) The parents will call immediate attention to undesirable behavior. b) The parents will raise their voices when reprimanding the child. c) The parents will verbalize requests for behavior in negative terms. d) The parents will set flexible rules
The parents will call immediate attention to undesirable behavior.
The mother of a newborn is voicing concerns about her baby's ability to hear. The nurse should tell the mother: a) She can test the baby's hearing by clapping her hands 24 inches (60 cm) from the infant's head. b) Most American states and Canadian jurisdictions mandate hearing tests for infants. c) Her concern is unfounded because hearing problems are rare in newborns. d) Newborns cannot hear well until they are at least 6 weeks old.
Most American states and Canadian jurisdictions mandate hearing tests for infants
A nurse is giving discharge instructions to a parent of a 13-month-old infant who weighs 18 lb (8.2 kg). Which statement by the parent demonstrates understanding of car-seat safety? a) "If I have a sports utility vehicle, my infant may ride in a rear-facing or front-facing car seat." b) "My infant may ride in a front-facing car seat as soon as he weighs 21 pounds." c) "My child will need to ride in a rear-facing care seat until he's 3 years old." d) "My infant may ride in a front-facing car seat because he's 1 year old."
My infant may ride in a front-facing car seat as soon as he weighs 21 pounds."
The nurse is caring for a 38-year-old primigravida in the third trimester of pregnancy. The nurse plans to assess the client for symptoms of: a) Pelvic inflammatory disease. b) Preeclampsia. c) Cardiac overload. d) Ruptured membranes
Preeclampsia
A nurse is caring for a toddler who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report: a) generalized urticaria. b) mild temperature elevation. c) pain at the injection site. d) local swelling at the injection site
generalized urticaria
The nurse is assessing a pregnant client using Leopold's maneuvers. Which of the following nursing actions are appropriate for this assessment? Select all that apply. a) Palpate the client's upper abdomen using both hands b) Note the shape and consistency of the palpated part c) Have the client refrain from voiding for 2 hours prior to the exam d) Position the client on her side e) The palpated part should be noted for mobility
• Palpate the client's upper abdomen using both hands • Note the shape and consistency of the palpated part • The palpated part should be noted for mobility
