HEALTH PROMOTION & MAINTENANCE

A mother tells the nurse that her 2-year-old child does not want anything to do with toilet training and yells "No!" consistently when she tried to toilet train. According to Erikson, the nurse interprets that the child is experiencing which psychosocial crisis? 1. Autonomy vs. Shame & Doubt 2. Initiative vs. Guilt 3. Industry vs. Inferiority 4. Trust vs. Mistrust

Autonomy vs Shame & Doubt

Which instructions should be given to the client who is prescribed amiloride (Midamor) to treat hypertension? 1. Take the medication in the morning with breakfast 2. Withhold the medication if the blood pressure is high 3. Eat foods with extra sodium while taking this medication 4. Take the medication 2 hours after lunch on an empty stomach

Take the medication in the morning with breakfast

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered? 1. Initiative vs. Guilt 2. Industry vs. Inferiority 3. Identity vs. Role Confusion 4. Autonomy vs. Shame & Doubt

Autonomy vs. Shame & Doubt

The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places highest priority on discussing which risk factor? 1. Age older than 30 years 2. High-fat and low-fiber diet 3. Distant relative with colorectal cancer 4. Personal history of ulcerative colitis or gasterointestinal polyps

High-fat and low-fiber diet

A pediatric nurse is caring for a hospitalized preschooler who is in traction. The nurse determines that the appropriate play activity for the child is which of the following? 1. Drawing and coloring pictures 2. Reading from a large picture book 3. Hand sewing a picture 4. Listening to music

Drawing and coloring pictures

A nurse is trying to determine the client's adjustment to a new diagnosis 1. "Do you have anyone at home to help with housework and shopping?" 2. "How do you feel about the lifestyle changes you are planning to make?" 3. "Do you understand the use of your new medications?" 4. "Are you going to book your follow-up physician visit?"

How do you feel about the lifestyle changes you are planning to make?

A nurse is obtaining a history from a client diagnosed with coronary artery disease (CAD). The nurse determines that which items pertinent to the client's history are modifiable risk factors for CAD? 1. Age & obesity 2. Family history and stress 3. Hypertension and cigarette smoking 4. Gender and identity

Hypertension and cigarette smoking

A nurse is reviewing the record of a client with a diagnosis of cervical cancer. Which risk factor associated with this type of cancer does the nurse expect to note in the client's record? 1. Single female, no children, has infrequent sexual intercourse 2. Sexual intercourse with a single sex partner 3. Sexual intercourse with circumcised males 4. History of human papilomavirus

History of human papilomavirus

When assessing a child with a dog bite, which of the following is a priority question for the nurse to ask? 1. "How old is the dog?" 2. "Did the dog have rabies?" 3. "Are the child's immunizations up-to-date?" 4. "Did the dog have all of its recommended shots?"

Are the child's immunizations up-to-date?

The nurse working at a health screening clinic gathers data from a client to identify the client's modifiable risk factors associated with coronary heart disease. Which risk factors and modifiable? (Select all that apply.) 1. Is a cigarette smoker 2. Is physically inactive 3. Is female, age 45 4. Is an African American 5. Has a family history of heart disease 6. Has a personal history of diabetes mellitus

*Is a cigarette smoker *Is physically inactive *Has personal history of diabetes mellitus

A nurse is conducting a health-screening clinic. The nurse interprets that which of the following clients participating in the screening has the greatest need for instruction to reduce the risk of developing respiratory disease? 1. A 50-year-old smoker with cracked asbestos lining on basement pipes in the home 2. A 40-year-old smoker who works in a hospital 3. A 36-year-old who works with pesticides 4. A 25-year-old who does woodworking as a hobby

A 50-year-old smoker with cracked asbestos lining on basement pipes in the home

Which client is at the greatest risk for developing a skin disorder? 1. An athlete 2. An adolescent 3. A client who uses an indoor tanning bed 4. An older client

A client who uses an indoor tanning bed

A nurse has performed the Weber test and notes that the client states that the sound is heard in both ears. The nurse interprets this finding as: 1. A sensorineural and conductive loss hearing 2. A conductive hearing loss in the right ear 3. A normal finding 4. The presence of nystagmus

A normal finding

Which information would the nurse provide to the client about the early signs of testicular cancer? 1. Sharp pain is felt 2. A palpable, painful lump is present 3. A sensation of scrotal heaviness without a lump is noted 4. A palpable, painless lump with possible scrotal enlargement is found

A palpable, painless lump with possible scrotal enlargement is found

Which of the following problems is the priority for a first-time mother who expresses anxiety regarding infant care? 1. Inability to cope 2. Expressions of grief that are dysfunctional 3. Verbal statements that indicate low self-esteem 4. Lack of knowledge about caring for the infant

Lack of knowledge about caring for the infant

A client with chronic renal failure is prescribed a protein-restricted diet. Which of the following sources of incomplete protein does the nurse instruct the client to avoid? 1. Nuts 2. Eggs 3. Milk 4. Fish

Nuts

Which of the following school-aged children are at the greatest risk for developing Osgood-Schlatter disease? 1. A 6-year-old in which epiphyseal closure has not occurred 2. An active adolescent boy involved in sports activities 3. A child who is on the school swim team 4. A child with a history of multiple streptococcal throat infections

An active adolescent boy involved in sports activities

It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? 1. At the umbilicus 2. One fingerbreadth below the umbilicus 3. Two fingerbreadths above the umbilicus 4. Two fingerbreadths below the umbilicus

At the umbilicus

The nurse is assisting in participating in a prostate screening clinic for men. The nurse questions each client about which sign of prostatism? 1. Ability to stop voiding quickly 2. Absence of post-void dribbling 3. Excessive force in urinary stream 4. Hesitancy when initiating urinary stream

Hesitancy when initiating urinary stream

A nurse is reviewing the record of a client admitted to the hospital for the treatment of bladder cancer. Which of the following risk factors related to this type of cancer would the nurse likely note in the client's record? 1. African-American female 2. Recorded age of 35 years 3. Occupation of computer analyzer 4. Drinks a pot of coffee every day

Drinks a pot of coffee every day

A client has a diagnosis of hypoparathyroidism. The nurse assesses that the client has a positive Trousseau sigh if the client has which of the following responses when tested? 1. Carpopedal spasm when a blood pressure cuff is inflated on the arm of 3 minutes 2. Spasm of the facial muscle when tapped below the temple 3. Pulling up of the knees when the head is bent onto the chest 4. Fanning and spreading of the toes when the sole of the foot is stroked

Carpopedal spasm when a blood pressure cuff is inflated on the arm of 3 minutes

A nurse is caring for a hospitalized school-aged child. The nurse determines that an appropriate play activity for the child is which of the following? 1. Playing with a push-pull toy 2. Playing "peek-a-boo" 3. Hand sewing a picture 4. Listening to music

Hand sewing a picture

Which of the following characteristics of lochia does the nurse expect to find for a client who is 2 hours postdelivery of a viable infant? 1. White lochia 2. Pink lochia 3. Serosanguineous lochia 4. Dark red lochia

Dark red lochia

A client has been diagnosed with pyelonephritis. The nurse interprets that which of the following health problems has placed that client at risk for this disorder? 1. Diabetes Mellitus 2. Orthostatic hypotension 3. Hypoglycemia 4. Coronary artery disease

Diabetes mellitus

A clinic nurse is interviewing an antenatal client. For which assessment question would the nurse identify the risk for toxoplasmosis parasite infection during pregnancy? 1. "How many sexual partners have you had since you became sexually active." 2. "Have you experienced any high fevers or unusual rashes during the first 6 weeks of your pregnancy?" 3. "Have you been exposed to children with rashes or gastrointestinal symptoms?" 4. "Do you have any cats at home, and do you handle the kitty litter?

Do you have any cats at home, and do you handle the kitty litter?

A nurse is reviewing the record of a client in the labor room and notes in the client record that the fetus is at minus one station. The nurse determines that the fetal presenting part is: 1. One inch below the iliac crest 2. One fingerbreadth below the symphysis pubis 3. One inch below the coccyx 4. One centimeter above the ischial spine

One centimeter above the ischial spine

A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the mother regarding the immunization schedule for this vaccine and tells the mother that the second vaccine is administered at: 1. Three years of age and then during the adolescent years 2. Eight months of age and then 1 year after the initial dose 3. Six months of age and then 8 months after the initial dose 4. One to 2 months of age and then 6 months after the initial dose

One to 2 months of age and then 6 months after the initial dose

A labor room nurse is assisting with a vaginal delivery. After the delivery of a viable newborn, the nurse notes that the umbilical cord lengthens and a spurt of blood flows from the vagina. The nurse interprets this occurrence as indicative of: 1. Abruptio placentae 2. Placenta previa 3. Placental separation 4. Uterine atony

Placental separation

A nurse is preparing to teach the parents of a child with anemia about the dietary sources of iron that are easy for the body to digest and absorb. Which food item should the nurse include in the teaching plan? 1. Fruits 2. Poultry 3. Apricots 4. Vegetables

Poultry

A nurse is caring for a hospitalized child who is immobilized as a result of traction. The nurse develops a plan of care and formulates outcomes for a nursing diagnosis of delayed growth and development related to immobilization and hospitalization. Using this nursing diagnosis, which of the following indicates a positive outcome for this child? 1. The fracture heals without complications 2. The child displays age-appropriate developmental behaviors 3. The caregivers verbalize the desire to provide safe and effective home care. 4. The child maintains normal joint and muscle integrity

The child displays age-appropriate developmental behaviors

Which of the following is the highest level of development that the nurse expects to note in a 30-month-old child? 1. The child builds a tower of two blocks 2. The child opens a doorknob 3. The child unzips a large zipper 4. The child puts on simple clothes independently

The child puts on simple clothes independently

A nurse is a reviewing the finds of a physical examination that are documented in a client's record. The nurse notes which piece of documented objective data? 1. The client's father had diabetes mellitus 2. The client has an allergy to acetylsalicylic acid (aspirin) 3. The client feels very tired 4. The client's left eyelid droops

The client's left eyelid droops

A nurse is participating in a health fair and is teaching individuals about ways to decrease dietary risk factors for cancer. The nurse includes which piece of information in the instructions? 1. Limit intake of foods that contain fat 2. Limit intake of vegetables 3. Increase intake of processed meats 4. Decrease intake of fiber

Limit intake of foods that contain fat

An appropriate goal for a client who overeats and is overweight is: 1. Make a list of food preferences 2. Weighs self daily with the same scale 3. Loses 2 pounds each week 4. Identifies the nutritional value of selected foods

Loses 2 pounds each week

A client has undergone surgery for cataracts. The nurse instructs the client to call the physician for which of the following complaints? 1. Sudden decrease in vision 2. Gradual resolution of eye redness 3. Eye pain relieved by acetaminophen (Tylenol) 4. Small amounts of dried matter on the eyelashes after sleep

A sudden decrease in vision

To assess the status of the median nerve, which of the following does the nurse perform? 1. Have the client spread all of the fingers wide and resist pressure 2. Monitor for flexion of the biceps by having the client raise the forearm. 3. Have the client move the thumb toward the palm and back to the neutral position 4. Have the client grasp the nurse's hand while noting the client's strength of the first and second fingers

Have the client grasp the nurse's hand while noting the client's strength of the first and second fingers

A nurse performs an assessment on a 9-month-old infant. Which finding indicates a physiological problem? 1. Head lag is noted when pulled to sitting 2. Inability to stand without support 3. Creeping or crawling along the floor 4. Absence of rooting reflex

Head lag is noted when pulled to sitting

A nurse employed in a well-baby clinic is collecting data regarding the language and communication developmental milestones of a 7-month-old infant. The nurse watches the infant for which language developmental milestone that begins to occur in the infant at this developmental age? 1. Use of gesture 2. Babbling sounds 3. Cooing sounds 4. Increased interest in sounds

Increased interest in sounds

A nurse is monitoring an adolescent client for signs of depression. To recognize depression, the nurse understands that a normal adolescent: 1. Spends a lot of time self-reflection, so it is normal to become depressed 2. Likes the unkempt look, so does not care that much about appearance 3. Is moody and acts out a lot 4. Likes to stay up late

Likes to stay up late

A client is trying to modify potential risk factors for coronary artery disease (CAD). Laboratory screening indicates that the total cholesterol level is 183 mg/dL, the low-density lipoprotein (HDL) level 65 mg/dL. The nurse determines that these results: 1. Put the client at very high risk for coronary artery disease 2. Put the client at slight-to-moderately high risk for CAD 3. Put the client at low risk for CAD 4. Are inconclusive unless the triglyceride level also is screened

Put the client at low risk for CAD

The nurse determines that which population is at highest risk for tuberculosis (TBI)? 1. Persons admitted to the hospital for day surgery 2. Children older than 6 years of age in a summer school program 3. Residents of a long-term care 4. A family who has recently emigrated from Australia

Residents of a long-term care facility

The school nurse is planning to give a class on testicular self-examination (TSE) at a local high school. The nurse plans to include which instruction on a written handout to be given to the students? 1. Perform the self-examination every other month 2. Expect the self-examination to be slightly painful 3. Perform the self-examination after a cold shower 4. Roll the testicle between the thumbs and forefingers

Roll the testicle between the thumbs and forefingers

A clinic nurse is performing an assessment on a client diagnosed with primary hypertension. The nurse would do which of the following to assess the client's blood pressure accurately? 1. Use a cuff with a rubber bladder that encircles at least 50% of the limb. 2. Ensure that the client has not had nicotine or caffeine in the past 10 minutes. 3. Seat the client with the arm bared, supported, and at heart level 4. Measure the blood pressure after the client is seated quietly for 1 minute

Seat the client with the arm bared, supported, and at heart level

The nurse is preparing a poster for a booth at a health fair to promote primary prevention of cervical cancer. The nurse should include which recommendation on the poster? 1. Use a commercial douche on a daily basis 2. Perform monthly breast self-examinations (BSE) 3. Seek treatment promptly for infections of the cervix 4. Use oral contraceptives as a preferred method of birth control

Seek treatment promptly for infections of the cervix

A client with low back pain asks the nurse which type of exercise will best strengthen the lower back muscles. The nurse tells the client to participate in which beneficial exercise? 1. Tennis 2. Diving 3. Canoeing 4 Swimming

Swimming

The nurse monitors an 18-month-old child. Which is the highest level of motor development expected to be observed in a child of this age? 1. The child builds a tower of two blocks 2. The child builds a tower of four or five blocks 3. The child snaps large snaps 4. The child puts on simple clothes independently

The child builds a tower of four or five blocks

Which of the following clients is at lowest risk for developing pneumonia during hospitalization? 1. A postoperative client who had local anesthesia 2. A client with a 20 pack-a-year history of smoking 3. A postoperativ client who caught a cold 4. An older client with diabetes mellitus admitted from a nursing home

A postoperative client who had local anesthesia

A nurse is planning home care for a 9-year-old child who is newly diagnosed with type 1 diabetes mellitus. which of the following is an age-appropriate activity for health maintenance? 1. Independently self-administering insulin 2. Administering insulin drawn up by an adult 3. Making independent decisions with regard to sliding-scale coverage of insulin 4. Having an adult assist in the self-administration of insulin and glucose monitoring

Independently self-administering insulin

The nurse is caring for an infant classified as small for gestational age (SGA). In assessing the maternal history, the nurse will check for which major factor that may result in an SGA infant? 1. Use of tobacco 2. Marital status 3. Maternal blood type 4. Maternal age

Use of tobacco

A nurse prepares to discharge a female client who is 48 years old and experiencing family-related stress. Which goal does the nurse include to help the client achieve her primary developmental task? 1. Improve the client's acceptance of aging 2. Help the client to resume her familial role 3. Develop the client's critical thinking skills 4. Adjust her lifestyle to ease stress response

Help the client to resume her familial role