Health, Wellness & Illness
While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, the amniotic membranes rupture spontaneously. The client's cervix is 5-cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is normal. What should the nurse do first? Note the color, amount, and odor of the amniotic fluid. Prepare the client for imminent birth. Auscultate the client's blood pressure. Perform a vaginal examination to determine dilation (dilatation).
Note the color, amount, and odor of the amniotic fluid. Explanation: The nurse's first action when membranes rupture spontaneously is to check the odor, consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at 0 station, there is little likelihood of cord prolapse. However, when the fetal head is not engaged, checking for cord prolapse would be the priority when the membranes rupture spontaneously.After rupture of the membranes, vaginal examinations should be kept to a minimum to decrease the chance of infection.Although auscultating the client's blood pressure is important, it is not the priority following spontaneous rupture of membranes.Birth is not imminent if the client is 5-cm dilated. However, multigravid clients may progress quickly in labor, especially after rupture of the membranes.
A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? The most common treatment is metronidazole, which should eradicate the problem within 7 to 10 days. The potential for transmission to the client's sexual partner will be eliminated if condoms are used every time she and her partner have sexual intercourse. This condition puts the client at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.
This condition puts the client at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. Explanation: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx
On discharge, a client who underwent left modified radical mastectomy expresses relief that "the cancer" has been treated. What is most important for the nurse to include in discharge teaching? the importance of contacting the healthcare provider for temperature over 99.9°F (37.7°C) the need to schedule a follow-up appointment in 6 months the need for continued breast self-examination on the right breast the need for a high carbohydrate, low-fat diet
the need for continued breast self-examination on the right breast Explanation: The client's statement regarding the "cancer" being treated indicates the need for further teaching regarding breast cancer. Having breast cancer on the left side puts the client at greater risk for cancer on the opposite side and chest wall. Therefore, the nurse should stress the importance of monthly breast self-examinations and annual mammograms. Although the tumor was found, it was large enough to require a mastectomy and could put the client at risk for metastasis. Follow-up appointments should be monthly for the first few months and then scheduled at the direction of the healthcare provider. A temperature of 99.9°F (37.7°C) does not require notification of the healthcare provider. It will be important for the client to increase protein and calories in order to promote wound healing. A high-carbohydrate, low-fat diet may not be appropriate for this client
A client takes prednisone for an acute exacerbation of rheumatoid arthritis. The nurse determines the client understands how to take the prednisone when the client makes which statement? "I can stop taking the prednisone as soon as my joints feel better." "It's important for me to increase my sodium intake while I am taking this medication." "It's best if I take this medication with some food." "I shouldn't be concerned if I lose a little weight while I take the prednisone."
"It's best if I take this medication with some food." Explanation: Prednisone is a gastrointestinal irritant that is best taken with food. The client should not abruptly stop taking the prednisone when their joints feel better. Rather, the drug must be tapered slowly. Abrupt withdrawal can precipitate a return of the symptoms. Sodium intake should be reduced, not increased. The client will most likely retain fluids and demonstrate some weight gain.
A client who is receiving chemotherapy is not eating well but otherwise feels healthy. What should the nurse suggest the client eat? milkshake made with blueberries, bananas, and ice cream steak and French fries broiled chicken, green beans, and cottage cheese cereal with milk and strawberries
broiled chicken, green beans, and cottage cheese Explanation: A client receiving chemotherapy may experience loss of appetite along with nausea and vomiting but also requires a diet that includes protein, carbohydrates, and a small amount of fat. Carbohydrates are the first substance used by the body for energy. Proteins are needed to maintain muscle mass, repair tissue, and maintain osmotic pressure in the vascular system. Fats, in a small amount, are needed for energy production. Chicken, green beans, and cottage cheese are the best selection to provide a nutritionally well-balanced diet of carbohydrate, protein, and a small amount of fat. Cereal with milk and strawberries and the milkshake made with fruit and ice cream contain a large number of carbohydrates and not enough protein. Steak and French fries provide some carbohydrates and a good deal of protein; however, they also provide a large amount of fat.
A 25-year-old client tells the nurse that she would like to become pregnant, but she has been diagnosed with blocked fallopian tubes due to pelvic inflammatory disease. When helping the client explore infertility treatment options, what is most appropriate for this client? zygote intrafallopian transfer menotropin therapy gamete intrafallopian transfer in vitro fertilization
in vitro fertilization Explanation: Because this client's tubes are blocked, in vitro fertilization would be the most appropriate. After ova are removed surgically from the client and fertilized outside the uterus, the fertilized ova are introduced vaginally through a special tube through the cervix to the uterus for implantation, completely bypassing the fallopian tubes. Gamete intrafallopian transfer, the transfer of ova into a patent fallopian tube for fertilization, would be inappropriate for client with blocked fallopian tubes. Zygote intrafallopian transfer involves oocyte retrieval then fertilization. After fertilization, the fertilized eggs are transferred into the client's fallopian tubes. This is not an option for a client who has blocked tubes. Menotropin therapy would be appropriate if the client was experiencing ovarian dysfunction.
An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Which anticipatory guidance for the parents and adolescent is most important? the adolescent's future plans need for a lot of psychological support the adolescent's sterility technique for monthly testicular self-examinations
technique for monthly testicular self-examinations Explanation: Because the incidence of testicular cancer is increased in adulthood among children who have had undescended testes, it is extremely important to teach the adolescent how to perform the testicular self-examination monthly. The undescended testicle is removed to reduce the risk for cancer in that testicle. Removal of a testis would not necessarily make the adolescent sterile because the other testicle remains. Although discussing the adolescent's future plans is important, it is not the priority at this time. Because the adolescent has been dealing with the situation for a long time, the need for a sports physical at this time should not be a cause of emotional distress requiring a lot of psychological support.
A pregnant client, who is originally from another country, is admitted to the hospital in labor. During the admission process, the spouse tells the nurse that the client will not receive any pain medication during the process. The spouse then waits in the waiting room. As the birthing process continues, the nurse asks the client if she needs pain medication. She declines the offer and reminds the nurse by saying, "My spouse told you I cannot have any pain medicine." What is the nurse's best response to the client? "I am going to talk to the provider about this." "I am sorry. I do not want to offend your husband." "I want to advocate for you and assist with the pain during this process." "I think that this is extreme. Pain medication will not affect the child."
"I want to advocate for you and assist with the pain during this process." Explanation: Being a client advocate is important during the birthing process. Respecting the client's decisions is important, but decisions can be changed during this painful process. A nurse should advocate for the client and the client's needs but also respect the client's wishes.
After teaching a client about bottle-feeding, which client statement indicates the need for additional teaching? "Bottle-fed babies will usually regain their birth weight by 10 to 14 days of age." "Whole milk is an acceptable alternative to formula once the baby is 4 months old." "Bottle-fed babies up to 6 months of age may gain as much as 1 oz (30 g) a day." "Iron-fortified formulas are usually recommended for newborns."
"Whole milk is an acceptable alternative to formula once the baby is 4 months old." Explanation: Neither unmodified cow's milk nor whole milk is an acceptable alternative for newborn nutrition. The protein content in cow's milk is too high, is poorly digested, and may cause gastrointestinal tract bleeding.Bottle-fed infants may gain as much as 1 oz (30 g) a day up to age 6 months.Iron-fortified formulas are recommended.Bottle-fed neonates may regain their birth weight by 10 to 14 days of age.
A nurse in a well-child clinic is assessing children for scoliosis. Which child is most at risk for scoliosis? 10-year-old girl teenage boy 6-year-old girl 8-year-old boy
10-year-old girl Explanation: The 10-year-old girl is most at risk because scoliosis is five times more common in girls than boys, and its peak age of incidence is between ages 8 and 15. The 8-year-old boy or a teenage boy may develop scoliosis but it's more common in females. A 6-year-old girl is typically too young to be diagnosed with scoliosis.
A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? Client will state that she may attempt another pregnancy after 3 months of follow-up care. Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge. Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative. Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises.
Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative. Explanation: After a molar pregnancy, the client should receive follow-up care, including regular hCG testing, for 1 year because of the risk of developing chorionic carcinoma. After removal of a hydatidiform mole, the hCG level gradually falls to a negative reading unless chorionic carcinoma is developing, in which case the hCG level rises. A Pap test isn't an effective indicator of a hydatidiform mole. A follow-up examination would be scheduled within weeks of the client's discharge. The client must not become pregnant during follow-up care because pregnancy causes the hCG level to rise, making it indistinguishable from this early sign of chorionic carcinoma.
A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that she wants to breast-feed her neonate? Encourage breast-feeding to facilitate bonding. Discourage breast-feeding because HIV can be transmitted through breast milk. Encourage breast-feeding because it's healthier for the neonate. Encourage breast-feeding so that the client can get her rest and get healthier.
Discourage breast-feeding because HIV can be transmitted through breast milk. Explanation: HIV can be transmitted through breast milk, so breast-feeding should be discouraged in this case.
A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The neonate's parents ask the nurse what this score indicates. Which explanation is appropriate for the nurse to give the parents? a neonate who's moderately depressed a neonate who's in good condition a neonate who's mildly depressed a neonate who needs additional oxygen to improve the Apgar score
a neonate who's in good condition Explanation: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.
A client had a cystoscopy to remove a renal stone. Which laboratory data warrants immediate intervention by the nurse? a serum calcium level of 9.0 mg/dl (2.25 mmol/L) a urinalysis that shows microscopic hematuria a white blood cell count of 14,000 mm/dL (14.00 x 109/L) a creatinine level of 0.7 mg/dL (61.88 µmol/L)
a white blood cell count of 14,000 mm/dL (14.00 x 109/L) Explanation: The high white blood cell count signals infection and needs to be treated immediately. Microscopic hematuria may be related to trauma from the procedure and is not cause for alarm. The creatinine and calcium levels are normal.
A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of aromatherapy. biofeedback. acupressure. meditation.
acupressure. Explanation: The band on the wrist described by the client is an example of acupressure. Biofeedback involves connection to electrical sensors provide the person with information about the body so that the person can then focus actions to make small changes in the body to achieve the goal. Meditation involves deep thinking and reflection to focus the mind and body. Aromatherapy involves the use of essential oils to promote well-being
While caring for a female term neonate just born, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? Turner syndrome Potter syndrome ambiguous genitalia renal disorders
ambiguous genitalia Explanation: An enlarged clitoris with fusion of the posterior labia majora is associated with ambiguous genitalia. Ultrasound examination will reveal whether ovaries are present.Renal disorders are associated with the absence of a kidney and oliguria.Potter syndrome is a fatal condition involving renal agenesis and facial deformities.Turner syndrome is an autosomal anomaly in which there are 45 chromosomes. This syndrome also involves intellectual disabilities, a long spine, and delayed or absent sexual maturity.
A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine inversion. atony. involution. discomfort.
atony. Explanation: A large fetus, extended labor, stimulation with oxytocin, and traumatic birth commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow birth and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after childbirth.
A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? placing antibiotic ointment in the neonate's eyes turning the neonate's head to the side to drain secretions checking for the umbilical cord around the neonate's neck assessing the neonate for respirations
checking for the umbilical cord around the neonate's neck Explanation: After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment is administered to the neonate after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The neonate's head isn't turned during delivery. After birth, the neonate is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after birth.
A community nurse is working with the family of an infant and teaching the parents about preventative health practices. What method of primary prevention the nurse to include in the teaching? performing screening tests testing grasp reflexes child-proofing the home testing suck reflexes
child-proofing the home Explanation: Primary prevention involves interventions that keep a health disorder from occuring. Teaching the parents how to child-proof the home is an example of primary prevention because it explains steps the parents can take to keep injury from occuring in the first place. Testing infant reflexes and performing screening tests are methods of seconday prevention; by attempting to identify signs and symptoms of disorders that have already occured, they help limit the impact of the disorder.
A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained? development of an increase in mobility fewer bruises than on admission decreased cardiac dysrhythmias fewer muscular spasms
development of an increase in mobility Explanation: This plan of care will help limit bone demineralization and reduce osteoporotic pain, thus promoting increased activity. The other choices are not reflective of osteoporosis.
A young client is admitted with a diagnosis of somatic symptom disorder, but declines analgesic medications. The nurse learns that the client finds relief in regular hypnotherapy practice. The best response of the nurse should be: "Explain how you find the procedure helpful." "Hypnosis is all entertainment and theater." "Hypnosis does not help with severe pain." "You have to believe in hypnosis for it to work."
"Explain how you find the procedure helpful." Explanation: The nurse is demonstrating acceptance and respect by asking the client to describe their experience with pain. Evidence-based research shows that hypnosis is effective whether or not the person being hypnotized believes in the treatment. It is not true that hypnosis does not provide relief for severe pain. It is silly and demeaning to deny the therapeutic effect of hypnosis.
A pregnant client is experiencing a thin, odorless, vaginal discharge. What should the nurse instruct the client to do to prevent vaginal infections? "Don't worry, nothing will happen to you." "Try wearing a panty liner and discarding it after every urination." "When you notice the discharge, take a bath and come into the office." "Wash more thoroughly."
"Try wearing a panty liner and discarding it after every urination." Explanation: A thin, odorless vaginal discharge is typical during pregnancy. Keeping the area clean and dry by wearing panty liners will prevent infection. Taking a bath before an office visit to assess the discharge will wash away the bacteria needed for examination. Telling the client that she should not worry or that she is not keeping herself clean is not valid and does not offer reassurance.
A client is at an ideal weight when she conceives. During a prenatal visit 2 months later, the client asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response? "You should gain 10 to 15 lb (4.5 to 6.8 kg)." "You should gain 25 to 35 lb (11.3 to 15.9 kg)." "You should gain less than 10 lb (4.5 kg)." "You should gain 16 to 24 lb (7.3 to 10.9 kg)."
"You should gain 25 to 35 lb (11.3 to 15.9 kg)." Explanation: For a client entering pregnancy in the ideal weight range, a gain of 25 to 35 lb (11.3 to 15.9 kg) is adequate to meet her needs and the needs of her fetus. Weight gain below the recommended range predisposes the client to complications during pregnancy, labor, and birth.
A primiparous client planning to breastfeed 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 produce milk within what time period? 12 hours 24 hours 2 to 4 days 7 days
2 to 4 days Explanation: If the client begins breastfeeding early and often after birth, the breasts begin to fill with milk within 48 to 96 hours, or 2 to 4 days. The breasts secrete colostrum for the first 24 to 48 hours, which is beneficial to the neonate because of the immunoglobulins contained in colostrum.
A parent tells the nurse that their 4-year-old boy has developed some strange eating habits, including not finishing meals and eating the same food for several days in a row. The parent would like to develop a plan to correct this situation. When developing such a plan, what should the nurse and parent do? Restrict the availability of foods to those served at meal times. Allow the child to make some decisions about the foods they eat. Decide on a good reward for finishing the meal. Do not allow the child to leave the table until they have eaten the food.
Allow the child to make some decisions about the foods they eat. Explanation: Allowing a child to make some decisions about the foods they eat and not insisting that they finish meals can avoid power struggles. Refusing to finish meals and to eat certain foods is normal behavior for a preschool-age child. It is important to avoid tension at mealtime and to avoid confrontation about food, which should not be used as a bribe or a reward. Rewarding a child for what is eaten can lead to power struggles between the parent and child over food. Restricting foods should be avoided; restriction can provoke power struggles and confrontation, thereby increasing tension. Not allowing the child to leave the table until their food is finished can provoke power struggles and confrontation, thereby increasing tension.
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? Make an appointment because the client needs to be evaluated. Tell the client to go to the hospital; she may be experiencing signs of heart failure. Arrange for the client to be admitted to the birth center and prepare for birth. Explain that these are expected problems for the latter stages of pregnancy.
Explain that these are expected problems for the latter stages of pregnancy. Explanation: The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes caused by the growing uterus and pressure on the diaphragm. These signs don't indicate heart failure. The client doesn't need to be seen or admitted to the birth center.
An adolescent tells the nurse that they would like to use tampons during their period. What should the nurse do first? Assess the client's usual menstrual flow pattern. Provide information about preventing toxic shock syndrome. Refer the client to a specialist in adolescent gynecology. Determine whether the client is sexually active.
Provide information about preventing toxic shock syndrome. Explanation: The nurse should provide the adolescent with information about toxic shock syndrome because of the identified relationship between tampon use and the syndrome's development. Additionally, about 95% of cases of toxic shock syndrome occur during menses. Most adolescent females can use tampons safely if they change them frequently. Using tampons is not related to menstrual flow or sexual activity. There is no need to refer the girl to a gynecologist; a nurse can provide health teaching about tampon use.
A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of the fetus. The client's BPP score is 8. What does this score indicate? The fetus isn't in distress at this time. The client should repeat the test in 24 hours. The fetus should be delivered within 24 hours. The client should repeat the test in 1 week.
The fetus isn't in distress at this time. Explanation: The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may be repeated if the score isn't within normal limits.
A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find
irritability and poor sucking. Explanation: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in neonates with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.
The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience what type of pain? no pain light pain sharp pain moderate pain
no pain Explanation: According to the gate-control theory of pain, a closed gate means that the client should feel no pain. The gate-control theory of pain refers to the gate-control mechanisms in the substantia gelatinosa that are capable of halting an impulse at the level of the spinal cord so the impulse is never perceived at the brain level as pain (i.e., a process similar to keeping a gate closed).
The nurse is aware that frequent repositioning in bed will assist in the prevention of which condition for a client?
pneumonia Explanation: By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis.
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother pushes only the tip of the nipple into the neonate's mouth. uses a nipple with regular size openings. makes sure that the nipple fills with formula. strokes the neonate's lips gently with the nipple.
pushes only the tip of the nipple into the neonate's mouth. Explanation: The tip of the nipple shouldn't be pushed into the neonate's mouth. To suck effectively, the neonate needs to compress the entire nipple, not just the tip. Filling the nipple with formula reduces air swallowing. Stroking the neonate's lips gently with the nipple usually causes the mouth to open wide enough for nipple insertion. The mother should use a nipple with a regular size opening to avoid having too much formula enter the mouth once the neonate starts to suck.
A group has asked the nurse to discuss how lifestyle factors affect heart health. Which statements by members of the group would indicate that the teaching was effective? Select all that apply. "Gradually increasing my exercise levels will help enhance circulation through the heart." "Chewing tobacco rather than smoking it lessens the negative effect on the heart." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "Walking is excellent exercise to strengthen my heart."
"Gradually increasing my exercise levels will help enhance circulation through the heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "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." Explanation: Increasing exercise levels, diet changes, losing weight, and walking are all important elements of heart health. Chewing tobacco is still harmful to the body.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." "I will receive parenteral vitamin B12 therapy for the rest of my life." "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear."
"I will receive parenteral vitamin B12 therapy for the rest of my life." Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend? Buy well-fitting walking shoes. Elevate the feet several times a day. Wear a pair of knee-high support hose. Limit fluid intake after 8 pm.
Elevate the feet several times a day. Explanation: Elevating the feet will promote venous return and decrease foot and ankle edema. Limiting fluid intake is not recommended unless there are additional medical complications such as heart failure; limiting fluids after 8 pm can help with nocturia but time is irrelevant to edema prevention. Buying walking shoes will not necessarily decrease edema. Over-the-counter knee-high "support hose" are not the same as medical-grade graduated compression stockings, and there are some contraindications to compression that should first be ruled out. Therefore, the nurse should not recommend this intervention unless the elevation of legs fails to solve the edema, at which time the client should consult the health care provider about the use of medically approved compression stockings.
A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct? Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. To prevent fractures, the client should avoid strenuous exercise. The recommended daily allowance of calcium may be found in a wide variety of foods. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
The recommended daily allowance of calcium may be found in a wide variety of foods. Explanation: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.
A client with iron deficiency anemia is taking iron supplements. What nutrient should the nurse instruct the client to take the supplements with in order to increase the absorption of iron? milk food orange juice beta-carotene
orange juice Explanation: Ascorbic acid (vitamin C) increases iron absorption. Taking iron with a food rich in ascorbic acid, such as orange juice, increases absorption. Milk delays iron absorption. It is best to give iron on an empty stomach to increase absorption. Beta-carotene does not affect iron absorption.
A 32-year-old female client visits the family planning clinic and requests an intrauterine device for contraception. When the nurse is assessing the client, a history of which problem would be most important to determine? thrombophlebitis pelvic inflammatory disease previous liver disease coronary artery disease
pelvic inflammatory disease Explanation: The nurse should assess the client for a history of pelvic inflammatory disease (PID) because intrauterine devices have been associated with an increased risk for PID and perforation of the uterus.A history of thrombophlebitis, liver disease, or cardiovascular disease would be important to assess if the client were to receive oral contraceptives. Thrombophlebitis is a contraindication for oral contraceptives.
A nurse colleague states, "I don't believe in the influenza vaccination for myself or my children." What is the best response by the nurse? "You can be reported to management for not being up-to-date on your vaccinations." "Very young children and older adults should be prioritized to get the flu shot." "Research suggests that vaccinations are helpful to prevent the spread of influenza." "Flu vaccines are only effective for certain strains of flu and do not protect from all strains."
"Research suggests that vaccinations are helpful to prevent the spread of influenza." Explanation: The nurse should base the answer in science and evidence. The nurse should not focus on potential trouble with management, as this may seem threatening. While the effectiveness is limited to the targeted strains, this is not the most relevant information in the scenario. Healthcare professionals are prioritized for flu vaccines along with those with risk factors.
A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if: the neonate loses 10% to 15% of the birth weight within the first 2 days after birth. the neonate breast-feeds four times in 24 hours. the neonate latches onto the areola and swallows audibly. the neonate voids once or twice every 24 hours.
the neonate latches onto the areola and swallows audibly. Explanation: Breast-feeding is effective if the infant latches onto the mother's areola properly and if swallowing is audible. A breast-feeding neonate should void at least 6 to 8 times per day and should breast-feed every 2 to 3 hours. Over the first few days after birth, an acceptable weight loss is 5% to 10% of the birth weight.
A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find irritability and poor sucking. congenital defects such as limb anomalies. lethargy 2 days after birth. a flattened nose, small eyes, and thin lips.
"It's best if I take this medication with some food." Explanation: Prednisone is a gastrointestinal irritant that is best taken with food. The client should not abruptly stop taking the prednisone when their joints feel better. Rather, the drug must be tapered slowly. Abrupt withdrawal can precipitate a return of the symptoms. Sodium intake should be reduced, not increased. The client will most likely retain fluids and demonstrate some weight gain.
A client comes to the clinic for evaluation. The client tells the nurse, "I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor." The client hands the nurse a printout of what the client found. Which response by the nurse would be most appropriate? "That is interesting, but you know, a brain tumor is really not a possibility." "Let us contact your primary care provider about this information." "That is ridiculous. You should never trust anything you read on the Internet." "Tell me more about where you found this information that you gave me."
"Tell me more about where you found this information that you gave me." Explanation: The Internet is full of health information, some of which is not always reputable or accurate. The best response by the nurse would be to investigate the client's information more closely and determine the validity of the information. The client obviously has concerns, and the nurse needs to address these concerns appropriately. By having the client tell the nurse more about the information, the nurse addresses the client's emotional needs as well as determines the validity of the information. Telling the client that a brain tumor is not a real possibility discounts the client's concerns. Telling the client that the idea is ridiculous is condescending and inappropriate. Contacting the primary care provider is inappropriate because it reinforces the client's misinformation.
A postpartum clinic nurse is assessing a client 4 weeks postpartum after a vaginal birth. What finding would indicate to the nurse that the client is experiencing normal hemodynamic changes occurring in the postpartum period? There is an increase in cardiac output by 10%. The client's experiences transient tachycardia. The blood pressure sitting is 108/62 mm Hg and standing is 94/56 mm Hg. The hematocrit rises from 34% to 40%.
The hematocrit rises from 34% to 40%. Explanation: Hemoglobin and erythrocyte values vary during the early postpartum period but they should approximate or exceed prelabor values within 2 to 6 weeks. As extracellular fluid is excreted, hemoconcentration occurs with a concomitant rise in hematocrit. Puerperal bradycardia with rates of 50 to 70 beats per minute commonly occurs during the first 6 to 10 days of the postpartal period. A client can experience orthostatic hypotension due to blood volume decreases following placental separation, contraction of the uterus, and increased stroke volume. Cardiac output begins to increase early in pregnancy and peaks at 20 to 24 weeks gestation at 30% to 50% above prepregnant levels. Cardiac output decreases during the postpartum period following placental separation, contraction of the uterus, and increased stroke volume.
A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities? administering digoxin to a client who has heart failure referring a client who reports joint pain to a healthcare provider specialist teaching a client who has asthma how to use a rescue inhaler obtaining a rubella titer on a woman who is planning to start a family
obtaining a rubella titer on a woman who is planning to start a family Explanation: Obtaining a rubella titer is a primary prevention activity. Rubella may cause birth defects when contracted during the first 3 months of pregnancy. Identifying those who do not have an immunity and then providing the vaccine is a primary prevention activity. The remaining selections fall under secondary and tertiary prevention.
The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse? Seek input from all groups and strive for consensus on what would benefit most or all of these people. Seek to promote homogeneity and common views rather than focus on differences. Support the implementation of the ideas of the majority. Make decisions based on findings from the community assessment.
Seek input from all groups and strive for consensus on what would benefit most or all of these people. Explanation: The responsibility is to conduct the community assessment and to identify the key needs. All members need to have representation in this process. It is best to strive for consensus on what the key issues are and to implement programs that would benefit most of the people, rather than responding to one interest group. Listening to the majority viewpoint or helping everyone to change their views and have homogeneity would not be effective. Decisions based on the community alone are also not an appropriate answer.
The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply. corn bagels apples pizza potatoes
potatoes apples corn Explanation: Celiac disease is an intolerance to the gluten factor of protein found in grains. Specific grains to be removed from the diet include wheat, rye, oats, and barley. Clients with a diagnosis of celiac disease can tolerate corn, fruits, and vegetables.
The client who is breastfeeding asks the nurse if they should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? More vigorous sucking is needed for bottle-feeding, so supplements should be avoided. Formula supplements can provide nutrients not found in breast milk. Water supplements should be primarily used to prevent jaundice. Formula feeding should be avoided to prevent interfering with the breast milk supply.
Formula feeding should be avoided to prevent interfering with the breast milk supply. Explanation: Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established.Bottle supplements are not appropriate to prevent jaundice, though if the neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breastfeeding, while others recommend increasing the frequency of breastfeeding.Breastfeeding is considered the best nutritional source for infants.Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast.
Which foods would a nurse encourage for a client with a red blood cell count of 3.2 million cells/cm3? Select all that apply. green leafy vegetables rice and beans turkey sandwich liver and onions back bacon
rice and beans liver and onions green leafy vegetables Explanation: Iron-rich foods such as liver, beans, and green leafy vegetables are considered to be stimulants for erythropoiesis. Turkey contains protein but does not contain high amounts of vitamin B 12, folic acid, or iron. Bacon is high in fat and does not stimulate erythropoiesis.
