Hollistic Exam 1

A parent calls the clinic nurse to say the child has shin splints after playing soccer. What instructions should the nurse provide this parent?

"Applying ice to the area will reduce the pain and swelling."

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her?

"At the age of 6 your child should be using a booster seat."

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

"Put your arm in this sleeve."

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims

The nurse should intervene immediately when observing the nursing assistive personnel (NAP) performing which activity with a stable client?

Teaching a client range-of-motion exercises

What factors must the nurse consider when creating a holistic plan of care? (Select all that apply.)

The client's developmental life stage The client's emotional context The client's physiologic health condition

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives?

The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

To prevent your legs from rotating outward."

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

Use of blankets, pillows, and stuffed animals in the crib

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

An infant has been born and diagnosed with a meningocele. Which action will the nurse incorporate into each contact with this infant?

inspection of the cystic sac on the child's back for leakage

When logrolling a client, the nurse should use supportive devices in turning the client in order to:

maintain the natural alignment of the client's body.

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

placing a small towel under the neck

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group

scoliosis

A nurse is reviewing the teaching plan about heart failure with a client. The nurse determines that learning in the affective domain has been achieved based on which client statement?

"I realize now just how important it is to watch how much salt I use."

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening?

"You seem unsure. Tell me your concerns about your surgery."

Which clients are most at risk for falling due to altered mobility? Select all that apply.

A client with a spinal cord injury An older adult client with an unsteady gait A client who requires crutches in unfamiliar health care settings

The nurse is reviewing the health care records of several families from the health care clinic. Which families should the nurse identify as being at risk for factors affecting their health? Select all that apply.

A family that is vegan A family that uses herbal medicine A family that fasts for religious purposes A family that receives public assistance A family that is headed by a single mother

A nurse is assessing a family with adolescents. The family consists of a father, mother, a 13-year-old son, a 14-year-old son from a previous marriage, and a 16-year-old daughter. Which statement by the parents would lead the nurse to suspect a potential risk factor for altered health with this family?

"Our 16-year-old just seems to butt heads with us at every turn."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the mostimportant statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear."

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A client who has leg strength and can cooperate with the movement

The nurse is educating a client with diabetes on how to better control blood sugar levels and recognize the symptoms associated with both hyperglycemia and hypoglycemia. The client is frequently admitted to the hospital due to elevated blood sugars. This education is an example of which level of health promotion?

Tertiary

The pediatric nurse practitioner (PNP) records "positive Gowers' sign" after finishing the assessment of a young boy. How will the student nurse reading the PNP's note interpret this?

The boy rises from the floor by walking his hands up his legs.

The nurse is caring for a child with a broken wrist that has just been placed in a cast. The nurse would elevate the arm to:

prevent edema.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

thrombus formation

The parents of a school-age child are meeting with the nurse for health promotional education for their child. The child has the following assessment data: a 7-year-old male with diabetes mellitus type 1 with a hemoglobin A1C level of 8.3%, a body mass index (BMI) of 31.7, and a BMI percentile of 99. What are the most appropriate learning diagnoses for this first session?

Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance.

What is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity?

Health

The nurse is assessing a family parented by a 60-year-old grandmother and her three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families?

Increased financial concerns

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach.

A client has been admitted to the hospital for treatment of pancreatitis secondary to alcoholism. The client states that it is nearly impossible to quit drinking because of the deep entrenchment of alcohol use in the client's circle of friends and line of work. As well, the client claims to have thought that drinking only beer and foregoing hard alcohol would prevent health problems. This client is exhibiting health consequences rooted in which human dimensions?

Sociocultural and intellectual

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting