Health Promotion Final
A nurse on a mental health unit is caring for a patient who has generalized anxiety disorder. The patient received a telephone call that was upsetting, and now the patient is pacing up and down the corridors of the unit. Which of the following actions should the nurse take? a. Instruct the patient to sit down and stop pacing. b. Allow the patient to pace alone until physically tired. c. Have a staff member escort the patient to her room. d. Walk with the patient at a gradually slower pace.
d. Walk with the patient at a gradually slower pace.
A nurse is caring for a patient who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? a. apply a fetal scalp electrode b. increase the rate of the IV infusion c. administer oxygen at 10 L/min via a nonrebreather mask d. change the patient's position
d. change the patient's position
The nurse assessed a woman who gave birth vaginally 12 hours ago. Which of the following findings would require further assessment? a. bright to dark red lochia b. 2nd degree laceration, approximated, moderate edema, light erythema absence of ecchymosis c. protrusion of the abdomen with slight seperation of abdominal wall muscle d. fundus firm at U+1cm and to the right of midline
d. fundus firm at U+1cm and to the right of midline
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? a. wash the cord daily with soap and water b. cover the cord with the diaper c. apply petroleum jelly to the cord stump d. give a sponge bath until the cord falls off
d. give a sponge bath until the cord falls off
The nurse is caring for a postpartum woman who received Methergine during her initial recovery after the baby was born. The expected outcome of care for the administration of this medication would be which of the following? a. relief from the pain of uterine cramping b. prevention of intrauterine infection c. reduction in the blood's ability to clot d. limitation of excessive blood loss that is occurring after birth
d. limitation of excessive blood loss that is occurring after birth
A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take first? a. report the suspected abuse to the authorities b. ask a psychiatrist to talk with the parents c. separate the child from the parents d. obtain a detailed history
d. obtain a detailed history
A nurse is presenting educational materials for a group of middle-aged patients about menopausal hormone therapy following total hysterectomy. Which of the following information should the nurse include in the information? a. take at different times of the day b. take an extra dose if missed a day c. prevents from having a cerebral hemorrhage d. prevents osteoporotic fractures
d. prevents osteoporotic fractures
The nurse assessed the following patients at 24 hours after giving birth, which is least likely to experience after pains? a. primipara who is breastfeeding her twins that were born at 38 weeks of gestation b. multipara who is breastfeeding her 10-pound full term baby girl c. multipara who is bottle-feeding her 8-pound baby boy d. primipara who is bottle-feeding her 7-pound baby girl
d. primipara who is bottle-feeding her 7-pound baby girl
A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to promote sleep? a. explain the source of the toddler's fears b. turn off the room lights c. encourage play exercises in the evening d. provide bedtime rituals
d. provide bedtime rituals
A nurse is performing discharge teaching for a client who has seizures with epilepsy and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? a. "I'll be glad when I can stop taking this medicine." b. "I will keep my doctor's appointment for follow up care." c. "I know that I should not switch brands of this medication." d. "I will notify my doctor before taking any other medications."
a. "I'll be glad when I can stop taking this medicine."
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make? a. "It sounds like you're having a difficult time." b. "Have you talked to your parents about this yet?" c. "Why do you think you are so anxious?" d. "How long has this been going on?"
a. "It sounds like you're having a difficult time."
A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? a. "Placing your child on her back when sleeping will decrease the risk of SIDS." b. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." c. "SIDS rates have been rising over the last 10 years." d. "Sleep apnea is the main cause of SIDS."
a. "Placing your child on her back when sleeping will decrease the risk of SIDS."
A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make? a. "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss." b. "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure." c. "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen." d. "The most common side effects are directly related to the use of anesthesia."
a. "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss."
A nurse is teaching a patient who has a new diagnosis of genital herpes. Which of the following statements by the patient indicates the need for further teaching? a. "Transmission of the disease will not occur when my lesions are gone." b. "Abstaining from sexual activity reduces the risk of transmission of the disease." c. "The use of condoms will reduce the risk of transmission." d. "Antiviral medications will not cure the infection."
a. "Transmission of the disease will not occur when my lesions are gone."
A nurse in a family planning clinic is caring for a 21-year-old female patient who is requesting oral contraceptives. The patient states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? a. "What part of the exam makes you most nervous?" b. "Don't worry, I will be with you during the exam." c. "All you need to do is relax." d. "A pelvic exam is required if you want birth control pills."
a. "What part of the exam makes you most nervous?"
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? a. A needleless syringe and a doll b. A video game c. A story book about a child who has diabetes d. A period of play in the playroom
a. A needleless syringe and a doll
A home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? (Select all that apply) a. Actions to reduce stress b. Identification of a social support system c. Referral to available community resources d. Instruction on client medication administration e. Expected physiological changes of the disease
a. Actions to reduce stress b. Identification of a social support system c. Referral to available community resources e. Expected physiological changes of the disease
A nurse is completing discharge teaching with a client. Upon discovery of which of the following barriers to learning the nurse identifies with this client, should the nurse interpret as a need to postpone the session? a. Acute pain b. Hearing loss c. Client's culture d. Motor impairment
a. Acute pain
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? a. Closed posterior fontanel b. Uses thumb and index fingers in a pincer grasp c. Lateral incisors d. Sitting steadily without support
a. Closed posterior fontanel
A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply) a. Have a parent stay with the child during procedures. b. Cluster invasive procedures whenever possible. c. Perform the procedure as quickly as possible. d. Allow the child to keep a toy from home with her. e. Use mummy restraints during painful procedures.
a. Have a parent stay with the child during procedures. c. Perform the procedure as quickly as possible. d. Allow the child to keep a toy from home with her.
A nurse in a drug and alcohol detoxification center is planning care for a patient who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority? a. Helping the patient identify positive personality traits b. Providing for adequate hydration and rest c. Confronting the use of denial and other defense mechanisms e. Educating the patient about the consequences of alcohol misuse
a. Helping the patient identify positive personality traits
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply) a. Irritability b. Euphoria c. Insomnia d. Low self-esteem e. Monotone speech
a. Irritability c. Insomnia d. Low self-esteem e. Monotone speech
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following is a nonmodifiable risk factor the nurse could include in the teaching? a. Race b. Obesity c. Cigarette smoking d. History of hypertension
a. Race
A home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching for coping strategies? (select all that apply) a. Stress reduction techniques b. Nutritional needs of the elderly c. Identification of a social support system d. Referral to available community resources e. Instruction on client medication administration
a. Stress reduction techniques b. Nutritional needs of the elderly c. Identification of a social support system d. Referral to available community resources
A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply) a. The reason why the child is taking the medication b. Written information about the medication c. Stopping the medication when the child feels better d. The adverse effects of the medication e. Using a kitchen spoon to administer the medication
a. The reason why the child is taking the medication b. Written information about the medication d. The adverse effects of the medication
A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.) a. apply breast milk to the nipples before each feeding b. change the infant's position on the nipples c. place breast pads inside the nursing bra d. massage the breasts and nipples prior to feeding e. start breastfeeding with the nipple that is less sore
a. apply breast milk to the nipples before each feeding b. change the infant's position on the nipples e. start breastfeeding with the nipple that is less sore
A nurse is performing Leopold maneuvers on a patient who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the patient's medical record? a. breech b. vertex c. shoulder d. mentum
a. breech
A student nurse is bathing a 1-day-old neonate. At the end of the bath, the student takes the infant's temperature and notes that it is down 1° F from his temperature prior to the bath. This drop in temperature may be caused by a. evaporation b. conduction c. convection d. radiation
a. evaporation
A nurse is collecting data about a family, Which of the following should the nurse include? (Select all that apply) a. medical history b. parental educational level c. child's physical growth d. support system e. stressors
a. medical history b. parental educational level d. support system e. stressors
A nurse is assisting a patient with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? a. rooting b. moro c. babinski d. stepping
a. rooting
A nurse on the labor and delivery unit is caring for a patient following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? a. the presenting part is 1 cm above the ischial spines b. the presenting part is 1 cm below the ischial spines c. the cervix is 1 cm dilated d. the cervix is effaced 1 cm
a. the presenting part is 1 cm above the ischial spines
A nurse is observing the electronic fetal heart rate monitor tracing for a patient who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? a. variable decelerations b. late decelerations c. accelerations d. early decelerations
a. variable decelerations
A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take? a. wrap the arm of the child's doll or toy prior to the procedure b. tell the child, "this will make your arm feel better." c. place a heated fan at the bedside to facilitate drying d. support the casted arm with a firm grasp
a. wrap the arm of the child's doll or toy prior to the procedure
A nurse is attending a group therapy session and is listening to clients who have chronic anxiety discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply) a. "I exercise aerobically three times a day for 30 minutes at a time." b. "I get 7 hours of sleep at night by skipping afternoon naps." c. "I think about being on my favorite beach vacation when I get anxious." d. "I tense and release my muscles, starting with my feet." e. "I see the glass as half-full when it starts looking empty."
b. "I get 7 hours of sleep at night by skipping afternoon naps." c. "I think about being on my favorite beach vacation when I get anxious." d. "I tense and release my muscles, starting with my feet." e. "I see the glass as half-full when it starts looking empty."
The nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the patient indicates understanding of the teaching? a. "I will place my baby on his stomach while sleeping." b. "I should remove extra blankets from his crib." c. "I should pad my baby's mattress so it is more comfortable." d. "I should place my baby's crib next to a heater to keep him warm at night."
b. "I should remove extra blankets from his crib."
The nurse is teaching the parents about suctioning the newborn. The teaching has been successful when the parents state a. "I need to use a new syringe after each use." b. "I should suction the mouth first then the nose." c. "I should put the syringe in the mouth and then squeeze it." d. "The need to suction will increase as the newborn grows."
b. "I should suction the mouth first then the nose."
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. "I don't take naps throughout the day." b. "I watch television until I fall asleep at night." c. "I have a glass of milk before going to bed at night." d. "I go to bed and get up routinely at the same time each day."
b. "I watch television until I fall asleep at night."
A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? a. "My child has recently lost both front top teeth." b. "The teacher says my child has to squint to see the board." c. "My child often cheats when we play board games." d. "Sometimes my child acts bossy with his friends."
b. "The teacher says my child has to squint to see the board."
A nurse is caring for an adolescent patient who tested positive for a sexually transmitted infection. The patient tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make? a. "Give your parents a chance; they'll understand" b. "You seem scared to talk to your parents" c. "If you want me to, I can tell your parents for you" d. "Your parents will have to be told why you are being admitted."
b. "You seem scared to talk to your parents"
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? a. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight b. A client who has terminal cancer and needs assistance with pain management c. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work d. A client who has dementia and needs help with activities of daily living
b. A client who has terminal cancer and needs assistance with pain management
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching? a. A jam sandwich b. A slice of cheese c. A cup of plain popcorn d. A serving of applesauce
b. A slice of cheese
A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take? a. Speak to the provider about adding an MAOI to the current medication regimen. b. Explain that antidepressants often take several weeks to be fully effective. c. Tell the client that the provider will need to change citalopram to a different medication. d. Recommend a sleep study be done on the client.
b. Explain that antidepressants often take several weeks to be fully effective.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse provide? a. Review the action of insulin therapy b. Explore the client's feelings about dietary modifications c. Have the client practice blood-glucose monitoring using a glucometer d. Ask the client to look at their menu and make meal choices for the next day
b. Explore the client's feelings about dietary modifications.
A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse include in the teaching as increasing the risk for contracting TSS? a. Mosquito bites b. High-absorbency tampons c. Travel to foreign countries d. Multiple sexual partners
b. High-absorbency tampons
A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? a. Document the bruises in the client's chart. b. Report the incident to the supervisor. c. Provide the client with a crisis hotline number. d. Discuss respite care with the client's family.
b. Report the incident to the supervisor.
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? a. The partner has hired a house cleaner. b. The partner has lost 20 pounds in the past 2 months. c. The partner redirects the client when the client is frustrated. d. The partner has placed locks at the top of the doors leading to the outside.
b. The partner has lost 20 pounds in the past 2 months.
A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? a. Set of building blocks b. Toy hammer and pounding board c. Picture book about hospitals d. Stuffed animal
b. Toy hammer and pounding board
A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names? a. Chickenpox b. Whooping cough c. Mumps d. Fifth disease
b. Whooping cough
A nurse is teaching a parent about implications of dealing with their child with autism. Which learning domain is the nurse using? a. cognitive b. affective c. psychomotor d. motivational
b. affective
A nurse is caring for a patient who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority? a. the patient reports weakness of the lower extremeties b. blood pressure 80/56 mm Hg c. temperature 38.2 C (100.8 F) d. the patient reports perfuse itching
b. blood pressure 80/56 mm Hg
The nurse recognizes the best measure to prevent abdominal distension following a cesarean birth is: a. rectal suppositories b. early and frequent ambulation c. tightening and relaxing abdominal muscles d. carbonated beverages
b. early and frequent ambulation
The nurse is caring for a patient 24 hours after giving birth, she states her sleep was interrupted the night before because of sweating and the need to have her gown and bed linen changed. The nurse's first action would be to: a. assess this woman for additional clinical manifestation of infection b. explain that sweating represents her body's attempt to eliminate the fluid that was accumulated during pregnancy c. notify her physician of the findings d. document the findings as postpartum diaphoresis
b. explain that sweating represents her body's attempt to eliminate the fluid that was accumulated during pregnancy
The nurse is assessing a postpartum women during the first 24 hours after birth, the nurse must be alert for signs that could indicate the development of postpartum physiologic complications. Which of the following signs would be of concern? (select all that apply) a. temperature of 99.8 F b. fundus-midline boggy c. lochia - 3/4 pad saturated in 3 hours d. pain in right calf with ambulation e. anorexia f. voids approximately 150ml to 200ml of urine for each of the first three voids after birth
b. fundus-midline boggy d. pain in right calf with ambulation e. anorexia
A nurse is caring for a postpartum mom; which of the following nursing actions would be least effective in facilitating parent attachment to their new infant? a. referring the couple to a lactation consultant to ensure continuing success with breastfeeding b. keeping the baby in the nursery as much as possible for the first 24 hours after birth so the mother can rest c. extending visiting hours for the woman's partner or significant other as they desire d. providing guidance and support as the parents care for their baby's nutrition and hygiene needs
b. keeping the baby in the nursery as much as possible for the first 24 hours after birth so the mother can rest
A nurse is assisting a family therapy group session. The son tells the nurse that he plans ways to make his sister look bad so his parents give him more privileges. The nurse identifies this dysfunctional behavior as which of the following? a. placation b. manipulation c. blaming d. distraction
b. manipulation
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? a. hypothermia b. respiratory distress c. accidental lacerations d. acrocyanosis
b. respiratory distress
A nurse is admitting a patient who requires droplet precautions due to influenza. Which of the following actions should the nurse take? a. place the patient in a room with negative airflow b. wear a mask when providing care to the patient c. ensure the patients room has HEPA filtration d. wear a gown when providing care to the patient
b. wear a mask when providing care to the patient
The nurse is caring for a newborn. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? a. "Mongolian spots can be found on the skin of many newborns." b. "This is a cephalhematoma, which can occur spontaneously." c. "A caput succedaneum occurs due to scalp edema." d. "This is erythema toxicum, which is a transient condition."
c. "A caput succedaneum occurs due to scalp edema."
The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make? a. "Let your child sleep in your bed with you." b. "Tell your child that monsters are not real." c. "Keep a night light on in your child's room." d. "Stay with your child until the child is asleep."
c. "Keep a night light on in your child's room."
Then nurse identifies the use of authoritative parenting style when she hears a parent make the following statement? a. "My son knows he better do what I say." b. "My daughter is mature enough to determine her own curfew." c. "My son understands that a part of learning responsibility is helping with household chores." d. "I only allow my daughter to date boys that attend our church."
c. "My son understands that a part of learning responsibility is helping with household chores."
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address? a. "My parents treat me like a baby sometimes." b. "I haven't gotten my period yet, and all my friends have theirs." c. "None of the kids at this school like me, and I don't like them either." d. "There's a big pimple on my face, and I worry that everyone will notice it."
c. "None of the kids at this school like me, and I don't like them either."
A nurse suspects that a family caregiver is neglecting an older adult client. Which of the following statements by the caregiver should the nurse identify as the highest priority to address? a. "We don't have air conditioning" b. "We usually have just two meals a day." c. "We only buy the prescription we can afford." d. "We cannot afford new batteries for his hearing aid."
c. "We only buy the prescription we can afford."
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? a. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." b. "Your baby should burp after each feeding." c. "Your baby should wet 6 to 8 diapers per day." d. "Your baby should sleep at least 5 hours between feedings."
c. "Your baby should wet 6 to 8 diapers per day."
A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching? a. "Limit caloric intake to avoid becoming overweight." b. "Share piercing needles only with close friends you trust." c. "Your need for sleep will increase during periods of growth." d. "Tanning beds are much safer then lying in the sun."
c. "Your need for sleep will increase during periods of growth."
A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake? a. 200 mL b. 270 mL c. 260 mL d. 240mL
c. 260 mL
A nurse is caring for a patient who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? a. Contractions occurring every 3 to 5 min b. Contractions are strong in intensity c. Contractions lasting longer than 90 seconds d. Client reports feeling contractions in lower back
c. Contractions lasting longer than 90 seconds
A nurse receives report about a patient who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. Contractions that last for 60 seconds each with a 4-min rest between contractions b. A contraction that lasts 4 min followed by a period of relaxation c. Contractions that last for 60 seconds each with a 3-min rest between contractions d. Contractions that last 45 seconds each with a 3-min rest between contractions
c. Contractions that last for 60 seconds each with a 3-min rest between contractions
A nurse is caring for a 6-month-old infant. Which of the following findings indicates to the nurse that the infant may be experiencing pain? a. Dry palms and feet b. Decreased muscle tone c. Furrowed brow d. Eyes wide open
c. Furrowed brow
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on psychomotor learning with this client, which of the following interventions should the nurse provide? a. Review the action of insulin therapy. b. Explore the client's feelings about dietary modifications. c. Have the client practice blood-glucose monitoring using a glucometer. d. Ask the client to look at their menu and make meal choices for the next day.
c. Have the client practice blood-glucose monitoring using a glucometer.
A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The patient's mother insists that the patient receive treatment. Which of the following actions should the nurse take? a. Initiate the IV per the parent's request b. Administer a sedative to calm the patient c. Notify the provider of the situation. d. Offer the patient an antiemetic.
c. Notify the provider of the situation.
A nurse is caring for a patient who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? a. Apply fundal pressure. b. Observe for the presence of a nuchal cord. c. Observe for crowning. d. Prepare to administer oxytocin.
c. Observe for crowning.
A nurse is caring for a patient whose Pap test cytology results are abnormal. Which of the following procedures should the nurse anticipate for this patient? a. Rectovaginal palpation by the provider b. dilation and curettage c. colposcopy d. human chorionic gonadotropin (hCG) test
c. colposcopy
A nurse is instructing a female patient about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the patient to check her temperature at which of the following times? a. 1 hour following intercourse b. on days 13 to 17 of her menstrual cycle c. every morning before arising d. before going to bed every night
c. every morning before arising
A nurse is teaching a postpartum patient about her Rho Gam injection. Which of the following should be included in the teaching? a. it destroys Rh antibodies in mothers who are Rh negative b. it destroys Rh antibodies in newborns who are Rh positive c. it prevents the formation of Rh antibodies in mothers who are Rh negative d. it prevents the formation of Rh antibodies in newborns who are Rh positive
c. it prevents the formation of Rh antibodies in mothers who are Rh negative
The nurse is caring for a woman who expresses a need to review her labor and birth experience. This behavior is most characteristic of which of the following phases of maternal postpartum adjustment? a. postpartum blues b. letting-go c. taking-in d. taking-hold
c. taking-in
A nurse is reinforcing teaching about contraceptive methods with a patient. Which of the following should the nurse recognize as a contraindication for diaphragm use? a. the patient is 42 years old b. the patient smokes cigarettes c. the patient has a history of toxic shock syndrome d. the patient has a 3-month-old infant
c. the patient has a history of toxic shock syndrome
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make? a. "I can arrange for a female assistive personnel to do your personal hygiene care." b. "The nurse assigned to care for you is very capable and cares for other women in this situation." c. "Your doctor is a man, so it seems like this should not be a problem." d. "I can review the assignments and arrange for a female nurse to care for you."
d. "I can review the assignments and arrange for a female nurse to care for you."
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? a. "I need to drink 8 cups of liquid each day." b. "I will need to empty my bladder regularly and completely." c. "I need to pay attention to the urge to void and go as necessary." d. "I will need to wipe my perineal area from back to front after urination."
d. "I will need to wipe my perineal area from back to front after urination."
A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I will keep my walker at the end of my bed." b. "I will keep the ceiling lights on in my room at night." c. "I will place a scatter rug at the front door of my house." d. "I will place a bath seat in my shower to use when I bathe."
d. "I will place a bath seat in my shower to use when I bathe."
A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction? a. "I will keep my baby's head elevated while he is feeding." b. "I will allow my baby to burp several times during each feeding." c. "My baby will have soft, formed brown stools." d. "I will tip the nipple so air is present as my baby sucks."
d. "I will tip the nipple so air is present as my baby sucks."
A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? a. 22/min b. 90/min c. 110/min d. 48/min
d. 48/min
A nurse is reviewing contraception options for four patients. The nurse should identify that which of the following patients has a contraindication for receiving oral contraceptives? a. A 26-year-old patient who has migraine headaches at the start of each menstrual cycle b. A 28-year-old patient who has a history of pelvic inflammatory disease c. A 32-year-old patient who has benign breast disease d. A 38-year-old patient who reports smoking one pack of cigarettes every day
d. A 38-year-old patient who reports smoking one pack of cigarettes every day
A nurse is instructing a male patient about a semen analysis to be done for suspected infertility. Which of the following should be included in the teaching? a. Leave the specimen at room temperature for 3 to 4 hr prior to transport to the laboratory. b. Collect the specimen using a condom with spermicidal lubricant. c. Refrigerate the specimen after collection. d. Abstain from ejaculation for at least 2 to 5 days prior to the test.
d. Abstain from ejaculation for at least 2 to 5 days prior to the test.
A nurse in an emergency department is caring for an adolescent patient who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take first? a. Discuss self-defense techniques with the patient. b. Inform the patient photographs of injuries are required for a police report c. Give the patient a bed bath prior to physical examination d. Ask the patient to describe the situation.
d. Ask the patient to describe the situation.
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority? a. Lock the doors to the unit and secure windows so they cannot be opened. b. Provide the client with plastic eating utensils for meals. c. Remove any objects from the client's environment that could be used for self-harm. d. Assign a staff member to stay with the client at all times.
d. Assign a staff member to stay with the client at all times.
A nurse midwife is examining a patient who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the patient is in labor? a. Amniotic fluid in the vaginal vault b. Brownish vaginal discharge c. Report of pain above the umbilicus d. Cervical dilation
d. Cervical dilation
A nurse is caring for a patient following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this patient? a. Maintain the patient in the lithotomy position. b. Perform vaginal examinations frequently. c. Remind the patient to bear down with each contraction d. Encourage the patient to empty her bladder every 2 hr.
d. Encourage the patient to empty her bladder every 2 hr.
A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching? a. Have the child remain at the table after meals to increase food intake. b. Emphasize the quantity, rather than the quality, of food consumed c. Add fruit juice to the child's diet to increase vitamin intake. d. Expect that food consumption might not decrease significantly.
d. Expect that food consumption might not decrease significantly.
A nurse is caring for a 12-month-old child who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the patient? a. Crayons and a coloring book b. Hanging crib toys c. Modeling clay d. Large building blocks
d. Large building blocks
A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form? a.Extended family b. Blended family c. Intergenerational family d. Nuclear family
d. Nuclear family
A nurse on a long-term care unit is creating a plan of care for a resident who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? a. Rotate assignment of daily caregivers. b. Provide an activity schedule that changes from day to day. c. Limit time for the client to perform activities. d. Talk the client through tasks one step at a time.
d. Talk the client through tasks one step at a time.
