Health Promotion and Maintenance

A 15 year old comes into the women's clinic with amenorrhea, breast tenderness, and urinary frequency. Which term should the nurse use to describe these signs/symptoms of pregnancy? 1. Probable 2. Positive 3. Presumptive 4. Early

3. Correct: Presumptive signs of pregnancy can be caused by conditions other than pregnancy.

Following report, which newborn infant should the nursery nurse assess first? 1. Positive Babinski reflex noted. 2. Has circumoral cyanosis. 3. Negative Ortolani's sign noted. 4. Has telangiectatic nevi.

2. Correct: Circurmoral cyanosis is bluish discoloration of and around the lips. It is an indicator of cyanotic heart defect.

Parents of school-aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates adequate understanding of appropriate use of TV in the family? 1. I don't allow my kids to watch violent TV shows. 2. They usually watch the kid shows on the kids' networks. 3. I don't usually worry about the time watching TV on weekends. 4. They can choose one TV show per day without my input.

1. Correct: Violent TV shows are not recommended for school-aged children. They may be disturbing and may desensitize them to violence.

A pregnant client asks a nurse, "How will I know when it is time to go to the hospital?" How should the nurse respond? 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

1. Correct: Yes! This is the appropriate teaching

The nurse is educating a client on the benefit of antioxidants. What statement should the nurse make sure to include? 1. Avoid harmful substances such as tobacco smoke and radiation. 2. Take a multivitamin daily and eat a balanced diet. 3. Engage in regular exercise and physical activity. 4. Maintain a normal body weight.

2. Correct: Several vitamins such as A, C, E, β-carotene, selenium, and lycopene are just some of the antioxidants found in a multivitamin and a balanced diet rich in colorful fruits and vegetables. Antioxidants capture the free radical, an electron emitted as part of the cellular process of oxidation, thus limiting cellular damage.

The nurse is performing a non-stress test on an anxious pregnant client who has lots of questions. What does the non-stress test tell the nurse? 1. That the baby is going to be a boy or girl 2. The baby is doing well and the placenta is providing enough oxygen at this time 3. That the baby's heart is healthy and there are no birth defects 4. That the mother is strong enough to undergo vaginal delivery

2. Correct: Yes, gives information about the placenta, uterus, and oxygenation.

A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What information should the nurse provide the client about spermicidal agents? 1. Are also effective in reducing vaginal fungal infections such as Candida albicans. 2. Eliminate bacterial and viral STIs. 3. Are more effective when used in conjunction with barrier methods, such as the diaphragm or condom. 4. Are used on an "as-needed" basis and exhibit few side effects.

3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival.

Which assessment by the nurse best indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

3. Correct: Yes, the trachea gets pushed to the other side from the tension, causing short of breath and labored breathing.

The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment? 1. Frequent low-calorie snacks. 2. Strict monitoring of intake and output. 3. Use of sweeping gaze when walking. 4. Setting the alarm clock for medication times.

4. Correct: Yes! Medication must be taken on time. Too early can cause complication of weakness and too late can cause extreme weakness to point of paralysis.

The nurse has been working on a health plan promoting increased physical activity for a sedentary client. Which client outcome would indicate that the interventions were successful? 1. Walks 10 minutes per day periodically. 2. Establishes a routine of 30 minutes of brisk walking three days per week. 3. Reports there is not enough time for exercise. 4. Reports walking daily for about two weeks out of the last three months.

2. Correct: Successful outcome would indicate a change in behavior. A routine of walking three times per week indicates behavioral change.

The nurse is caring for a primipara client at 27 weeks gestation. Which client learning need should the nurse identify as priority at this stage of pregnancy? 1. Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care

2. Correct: This client is entering the third trimester when the risk of preterm labor and delivery are highest.

What information would be included when a disaster relief nurse counsels parents of young clients who have experienced a disaster? Select all that apply: 1. Act as if things are normal. 2. Understand young children may exhibit separation fears and clinging. 3. Sedate the client until the crisis is resolved. 4. Understand nightmares and sleep disturbances may occur in young children. 5. Refrain from talking about the disaster.

2. & 4. Correct: Following a disaster, children exhibit a range of emotional and physiological reactions including separation, fear, and sleep issues. They may also appear confused, passive, fearful, and have somatic symptoms. They have difficulty talking about the event or identifying feelings.

The nurse has been working with an attractive teenage girl regarding appropriate nutrition. Which baseline data would support this teenager having a disturbed body image and the need for education on adequate nutrition? Select all that apply: 1. Reporting that she is pleased with her current weight that is within normal limits. 2. Complaining that she can never exercise enough to lose those saddle bags. 3. Stating that she can always work a little harder on school work and hobbies. 4. Client states, I try to eat only two meals a day to keep my weight down. 5. Client states, I have been trying to include more fruits and vegetables in my diet.

2., 3. & 4. Correct: Compulsive exercising may indicate an eating disorder or a risk for developing one. Perfectionism in school, sports, and hobbies may indicate low self-esteem, which is reflected in eating disorders. Compulsive adherence to routines for weight loss or control may indicate a risk for developing an eating disorder.

When caring for young adult clients, which developmental tasks would the nurse expect to see? Select all that apply: 1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. 5. Developing sense of fulfillment by volunteering in the community.

3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust.

Which comment by the mother indicates understanding of the diet needed to maintain health and adequate nutrition in the toddler? 1. "It is important to give my child low fat milk after one year of age". 2. "If the child won't eat new foods after three tries, he is not going to eat it". 3. "I think that the sooner one starts to give vitamins to children, the better". 4. "I try to provide whole grains, fruits, vegetables and meat daily".

4. Correct: A health promotion strategy to help meet the nutritional needs of the toddler includes offering a wide variety of foods.

The charge nurse is orienting a new nurse to the pediatric unit. Which teaching related to assessment is appropriate? 1. One assessment should be done daily on each client by the charge nurse. 2. An assessment should be done daily on each client at the beginning of the shift. 3. Assessments of clients should be updated as the nurse provides care to clients. 4. Assessments of clients should be done at the beginning of the shift and updated as nursing care is provided.

4. Correct: Assessment is ongoing; however, for each shift a baseline assessment should be done so the nurse can verify or make judgment regarding other findings throughout the 24 hour day. It is best to get the baseline as soon as possible once the shift begins, and update or reevaluate during the shift.

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? 1. "I will need to notify my primary healthcare provider if I develop a fever." 2. "I need to check my BP daily and report an increased B/P." 3. "I will tell my primary healthcare provider if I become easily fatigued." 4. "I will be on steroids for 3 months, then I will not have to take them."

4. Correct: Steroids are gradually reduced over a period of several weeks depending on the client's immunologic response to the transplant. However, some form of steroid (antirejection medication) must be taken for the entire time that the client has the transplanted kidney.

A client reports a diminished ability to visually focus on close objects and has also noticed a need for a well lit environment to enhance vision. To what would the nurse attribute these changes? 1. Normal changes associated with aging. 2. A cataract is forming. 3. Symptoms of a brain tumor. 4. Precipitated by diabetic retinopathy.

1. Correct: Aging results in stiffening of the lens, thus lessening the ability to focus. The retina is less sensitive to light, making accurate vision in low-light situations more difficult. Pupillary response diminishes, affecting the ability to adjust to changing light levels.

The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 30 minutes each day.

1. Correct: Best advice for pregnant women. The healthcare provider can individualize according to history and current status.

What is the priority nursing action for a pregnant client who has dilated to 6 centimeters while receiving an epidural? 1. Continuous monitoring of maternal blood pressure. 2. Frequent auscultation of the fetal heart rate. 3. Administer an IV fluid bolus of at least 500 mL during the procedure. 4. Frequent monitoring of the maternal temperature.

1. Correct: Decreased blood pressure is dangerous to both the laboring mother and fetus because of the decrease in cardiac output and placental perfusion. The most common negative side effect of epidural anesthesia is a precipitous drop in blood pressure.

The nurse is assessing a client admitted with acute gastritis. Which client information is most significant? 1. Takes ibuprofen for arthritis pain. 2. Had an upper respiratory infection two weeks ago. 3. Has a stressful job. 4. Enjoys spicy food.

1. Correct: Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). NSAIDs are highly associated with GI irritation.

The nurse is caring for a client that is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse's best response? 1. Bring the swaddled fetus to the mother. 2. Explain that the cause of death must be determined before she can see the baby. 3. Ask her if she is sure she wants to see the baby. 4. Tell her it would be better to wait until she is in her room before she sees the baby.

1. Correct: Let the grieving mother see the infant to continue the grieving process.

The nurse is caring for four postpartum clients. Which client is the highest priority for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

1. Correct: The surgical opening of the abdomen and uterus makes this the highest risk

What is the most important action for the nurse to take in order to prevent adverse drug reactions/interactions in an elderly client who takes multiple medications? 1. Implementing a thorough client assessment. 2. Instructing the client about adverse drugs reactions. 3. Explaining to the client that approximately 12% of hospital admissions of older adults are due to a drug reaction. 4. Teaching the client that the chances of adverse reactions are directly proportional to the number of medications taken.

1. Correct: To prevent complications of medication administration, such as adverse drug reactions and interactions, careful planning is priority. A thorough assessment of the client is vital when planning care.

A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription? 1. Promotes diuresis 2. Prevents injury 3. Promotes rest 4. Stimulates RBC production

1. Correct: Yes, bedrest and supine position promote diuresis.

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply: 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1., 2. & 3. Correct: Many elderly people have dental issues that affect chewing and intake of nutritionally dense foods. Appetite may decrease due to changes in taste, medications, depression or isolation. Many elderly people are active; therefore, it is important to assess each one individually in regard to activity levels.

A client who has been trying to lose weight reports to the nurse that it is just easier to stop by the fast food restaurant on the way home from work than to go home and prepare a meal. Which interventions could help the client stay on track? Select all that apply: 1. Suggest that the client eat yogurt and a piece of fruit upon returning home. 2. Suggest that the client order low fat options at the restaurants. 3. Encourage the client to pack a healthy snack to eat on the way home from work. 4. Inform the client that fast food does not contain healthy options. 5. Suggest that the client alter her route home from work in the evenings.

1., 2. & 3. Correct: The client is describing lack of convenience, a barrier to making better choices. The client can consume yogurt and fruit on the way home and still be making a good choice for dinner. Accessibility of healthier items will help the client stay on track. Availability of healthy foods will help the client stay on her food plan.

The nurse is establishing a health promotion plan for a client trying to improve personal eating habits and overall health. Which assessment measures should the nurse include? Select all that apply: 1. Body mass index 2. Waist circumference 3. Serum cholesterol, triglycerides 4. Calcium, sodium, potassium, iron 5. Cortisol levels

1., 2., 3. & 4. Correct: Body mass index is used to assess healthy weight and, indirectly, nutritional status. Waist circumference is important as percentage of fat is calculated using waist to hip ratio. Serum cholesterol and triglyceride levels help to assess nutritional status. Mineral levels are important indicators of nutritional status.

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan? Select all that apply: 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

1., 2., 3. & 5. Correct: The frequent washing in hot water removes dust mites. Adequate venting lessens the likelihood of fungal/mold spores. Carpet harbors dust and other allergens. The floors and upholstered furniture may harbor dust, pollen from clothing, and other irritants.

Which prescriptions are appropriate for the nurse to initiate on a newborn admitted to the nursery? Select all that supply: 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

1., 2., 3. & 5. Correct: This vaccine is recommended at birth to decrease the incidence of hepatits B virus. Mandatory prophylactic agent applied in newborn's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of newborn. PKU-Screening for phenylketonuria is not reliable until the newborn has ingested an ample amount of the amino acid, phenylalanine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time.

The client has been working on weight loss for 8 months and has been successful in losing 35 pounds (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase? Select all that apply: 1. On-going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 3. Reduced access to programmatic exercise plan. 4. Relapse prevention plan. 5. Continued peer support.

1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase.

Which teaching points should the nurse include when preparing the school-age child for heart surgery? Select all that apply: 1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 3. Explain that an endotracheal tube will be needed. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

1., 2., 4. & 5. Correct: Yes, they must talk about it. All of these will help decrease anxiety in postoperative period and reduces fear of the unknown.

The employee health nurse is designing a health promotion plan for a group of workers who have neck and back strain symptoms and repetitive movement pain from long periods of computer work. Which interventions should be included in the plan to reduce these symptoms? Select all that apply: 1. Suggest that the workers place the keyboard and mouse close to the body. 2. Adjust computer screen to below eye level. 3. Assess shoulder tension periodically and drop the shoulders. 4. Type with forearms parallel to the floor. 5. Keep elbows at the side when typing.

1., 3., 4. & 5. Correct: Keeping the keyboard and mouse close keeps the body in a more neutral position. Dropping the shoulders puts them in a relaxed position. As tension increases, the shoulders tend to rise. This position keeps the neck and back from being stretched, and keeps the body in a more neutral position. This allows the shoulders to stay in a more neutral position.

A 40-year-old client is curious about visible appearance changes related to menopause. What menopausal changes, in general, would the nurse explain to the client? 1. Bone loss and fractures. 2. Loss of muscle mass and increased fat tissue. 3. Improved skin turgor and elasticity. 4. A reduction in waist size.

2. Correct: Visible changes associated with menopause include loss of muscle mass, increased fat tissue leading to thicker waist, dryness of the skin and vagina, hot flashes, sleep abnormalities, and mood changes.

In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation? 1. The clients probably having an extramarital affair. 2. The developmental task at this stage is adjusting to the needs of more than two family members. 3. A relative or close friend should be consulted for help so the client can pursue activities outside the home. 4. The client should be referred to a psychotherapist for evaluation and care.

2. Correct: When children are born or adopted into a family, the established couple must adjust to supporting the physical and emotional needs of the additional family member. Additionally, the couple is engaged in developing an attachment with the child(ren) and coping with energy depletion and lack of privacy. These requirements may lead to a sense of unhappiness and frustration on the part of one or both parents.

The nurse wants to provide anticipatory guidance for a group of young mothers who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these mothers? Select all that apply: 1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 2. Let the parents know about the importance of letting the child do tasks alone. 3. Provide finger foods for the child to eat. 4. Your child will want you to provide emotional support when needed. 5. Assist your child with all tasks to promote independence.

2., 3. & 4. Correct: Letting the child do things on his or her own will promote a sense of self control and independence during this stage of autonomy versus shame and doubt. Finger foods allow for independence with eating. At this age the child becomes increasingly aware of his or her separateness from the mother. The need is for the mother to be available for emotional support when needed. However, if emotional needs are inconsistently met or if the mother rewards clinging, dependent behaviors and withholds nurturing when the child demonstrates independence, feelings of rage and fear of abandonment develop in adulthood.

The nurse is planning health promotion strategies for an older client on a limited, fixed income who is trying to increase activity. The client has been cleared for moderate physical activity by the primary healthcare provider. Which strategies would be appropriate for this client? Select all that apply: 1. Suggest that the client join a local gym for access to equipment and support. 2. Suggest contacting a neighbor so that they can walk each day in the neighborhood. 3. Encourage client to get up and walk around the house during each TV commercial break. 4. Suggest the client go to the community senior center for daily strengthening exercises. 5. Encourage client to use one-pound soup cans for muscle toning.

2., 3., 4. & 5. Correct: The neighborhood buddy is accessible and can be a source of emotional support, too, which increases the likelihood of continuing the plan. This activity is easily accessible and burns calories during the day or evening. Senior centers usually do not cost any money for the client and other seniors may help motivate the client to increase activity level. The use of ordinary items does not further strain a fixed income.

A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water

3. Correct: Comparing the appearance of the left knee to the right knee is the least invasive assessment and allows the nurse to assess if there is a change in the appearance of the affected knee to the unaffected knee.

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.

3. Correct: Genetics and body weight are the most important factors in the development of type 2 diabetes mellitus. The client cannot alter his genetics. Therefore, a normal body weight is imperative. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose.

The first day of a pregnant client's last menstrual cycle was October 20th. What does the nurse calculate as the client's expected date of confinement? 1. June 27 2. July 20 3. July 27 4. August 13

3. Correct: July 27th Naegele's rule: First day of LMP, add seven days, subtract 3 months, and add one year.

A female client has used Depo-Provera injections for birth control for several years. For the past 6 months, attempts to become pregnant have been unsuccessful. What instruction should the nurse provide to the client? 1. Be seen in the fertility clinic by a primary healthcare provider who specializes in this problem. 2. Have a sperm count performed on the client's partner. 3. Be aware that ovulation may not occur for many months after using Depo-Provera. 4. Ensure proper nutrition, rest, and establish an exercise program.

3. Correct: Ovulation ceases with Depo-Provera use. It may take 6 to 18 months to reestablish normal ovulation and menstruation.

The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal.

3. Correct: This decreases complications for the client on phenytoin. Gingival hyperplasia is a common side effect with phenytoin. The nurse should ensure that the client has good oral hygiene to prevent complications.

Which action should the nurse recommend to parents so that their home will be safer for a toddler? 1. Place the child in the center of an adult size bed when napping. 2. Buckle the child into the high chair if parents leave the room during a meal. 3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled over. 4. Allow the toddler to explore stairs in the home if supervised.

3. Correct: Top-heavy furniture, TVs and fish tanks can be pulled over by the toddler, especially if the child is trying to reach something on top of them.

The nurse is assessing a pregnant client returning for her one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time? 1. Blood glucose level 2. Ankles for edema 3. Twenty-four hour diet recall 4. Confirmation of last menstrual period

3. Correct: What is she eating? how much? Are the calories healthy? This is too much weight.

A home health nurse visits a recently discharged client with right-sided paresis due to a stroke. The nurse discovers that the spouse has been feeding the client. What action should the nurse take? 1. Instruct the spouse to require the client to feed independently. 2. Suggest the spouse hire an aide to feed and bathe the client. 3. Advise the spouse to consider an extended care facility for the client. 4. Determine why the spouse is not encouraging self-care by the client.

4. Correct: Because family members are important in promoting client self-care and preventing further illness, it is important to include family members in the teaching plan for the client. In a family support model, the goal is client self-care activities through formal and informal support systems.

What is the priority nursing action for a pregnant client in labor who is receiving an epidural and anesthetic for pain? 1. Perform a thorough skin prep of the insertion site. 2. Obtain the client's consent for the procedure. 3. Assure the client that residual effects of the procedure won't be felt. 4. Monitor maternal blood pressure.

4. Correct: Epidural anesthesia may result in distal vasodilation and a precipitous drop in maternal blood pressure, which will adversely affect placental blood flow.

The nurse enters a client's room and finds the client masturbating. Which action by the nurse would be most appropriate for the nurse to take? 1. Ask the client to stop 2. Ignore the client activity 3. Document the activity in the client's chart. 4. Quietly leave the room

4. Correct: Leaving the client's room, allows the client to have privacy.

A first generation Hispanic-American has been admitted to the psychiatric unit after being diagnosed with severe panic disorder. When developing the plan of care for this client, to which cultural background information should the nurse give priority? 1. Discuss treatment in terms of future plans for this client. 2. Do not use touch when communicating with this client. 3. Include the Protestant minister in the spiritual care of the client. 4. Allow family members to visit regularly.

4. Correct: Make allowances for individuals from other cultures to have family members around them and even participate in their care. Large numbers of extended family members are very important to African Americans, Native Americans, Asian Americans, and Hispanic-Americans. Denying access to these family support systems could interfere with the healing process.

As a treatment for impotency, a client is being taught to self-administer papaverine injections into the penis. Which statement indicates to the nurse that the client understands a serious adverse reaction associated with this injection? 1. "I should have a full erection within 15 minutes after I inject the medication." 2. "I can expect the injection site to be tender after the medication is injected." 3. "After injecting the medication into the penis several times, a plaque area may form." 4. "An erection lasting over 4 hours could cause tissue damage to my penis."

4. Correct: Papaverine is a vasoactive smooth muscle agent. An erection that lasts 4 hours or longer will decrease blood flow to the penile tissue and cause penile tissue damage. This is a serious adverse reaction.

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

4. Correct: The client may be bleeding, and that is an emergency!

The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which symptom below would cause the greatest concern? 1. Nasal congestion 2. Hiccoughs 3. Blood glucose of 150 4. Muscle spasms

4. Correct: This client could be pre-eclamptic and be at risk for seizures.