HURST QBank Health Promotion & Maintenance

The nurse is discussing television, video games, and internet usage with a group of parents who have 8 to 10 year old children. What should the nurse include? a. keep TVs, iPads, and other screens out of kids' bedrooms b. turn off all screens during meals c. allow screen time only after chores and homework are complete d. have a screen free day once a week e. limit screen time to 2 hours daily f. use screen time as a reward for good behavior

a, b, c, d, e

Which vaccines would a nurse participating at a health fair encourage a 65 year old adult to receive? a. influenza b. herpes zoster c. diphtheria d. pertussis e. pneumococcal vaccine f. MMR

a, b, c, d, e

The OB client, at 37 weeks gestation, is at the healthcare provider's office for a fetal NST. The client asks the nurse, "What will I have to do for this test?" What is an appropriate response by the nurse? a. "You need to relax so we can monitor the fetal monitors the entire time." b. "You will need to drink this solution and wait 30 minutes." c. "You must walk on the treadmill for at least 20 minutes." d. "You have to be in the lithotomy position like for a transvaginal ultrasound."

a. "You need to relax so we can monitor the fetal monitors the entire time."

The nurse is providing prenatal education for a couple expecting a first child. The expectant mother asks about fetal movements. What is the best explanation by the nurse? a. "You should feel activity between weeks 16 to 20." b. "The fetus is too small to feel any movements." c. "Maybe around the end of the 1st trimester." d. "It is different for each individual woman."

a. "You should feel activity between weeks 16 to 20."

Which client is at highest risk for septic shock? a. 75 year old with 3rd degree burns b. 30 year old with Type 2 diabetes c. 16 year old post emergency appendectomy d. 5 year old post PICC line placement

a. 75 year old with 3rd degree burns

A client arrives at the emergency room with severe right foot pain and is admitted with a diagnosis of hyperuricemia (gout). The nurse is reviewing diet habits and lifestyle with the client to develop a teaching care plan. The nurse has identified what habits that may contribute to an exacerbation of gout? a. a daily glass of white wine b. bacon and eggs on weekends c. smoking two cigars every day d. one half liter of soda daily e. baked cod twice a week f. a BMI of 31.5 kg/m2

a. a daily glass of white win d. one half liter of soda daily e. baked cod twice a week f. a BMI of 31.5 kg/m2

A laboring client, with gestational hypertension, has requested an epidural for pain management. What interventions should the nurse perform to minimize the risk of hypotension? a. administer an IV bolus of NS prior to placement b. place 15L of O2 via nonrebreather face mask c. avoid the supine position after placement d. hold nifedipine e. get out of bed slowly

a. administer an IV bolus of NS prior to placement c. avoid the supine position after placement

The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? a. age over 65 years b. history of grand mal seizures c. diabetes d. renal disease e. clients who reside in a nursing home

a. age over 65 years c. diabetes d. renal disease e. clients who reside in a nursing home

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake? a. beef liver b. feta cheese c. fresh spinach d. shrimp e. tuna f. tofu

a. beef liver b. feta cheese d. shrimp e. tuna

The pregnant client asks the clinic nurse if having a previous baby who developed jaundice soon after birth will increase her newborn's risk for development of hyperbilirubinemia. The nurse correctly identifies which risk factors that increase the incidence of jaundice in the newborn? a. blood incompatibility b. prematurity c. having a previously affected sibling d. birth trauma e. formula feeding

a. blood incompatibility b. prematurity c. having a previously affected sibling d. birth trauma

The nurse is telling the client about the benefits of cruciferous vegetables and their anticancer power. Which foods should the nurse recommend the clients should consume? a. broccoli b. potatoes c. garden cress d. cabbage e. brussels sprouts f. cauliflower

a. broccoli c. garden cress d. cabbage e. brussels sprouts f. cauliflower

What developmental milestone does the nurse expect to see in a 4 year old child? a. can say first and last name b. draws a person with 2 to 4 body parts c. copies a triangle d. can tell what is real and what is make believe e. sings a song from memory f. talks about likes and interests

a. can say first and last name b. draws a person with 2 to 4 body parts e. sings a song from memory f. talks about likes and interests

Which teaching points should the nurse include when preparing the school-age child for heart surgery? a. discuss postoperative discomfort and interventions b. show unfamiliar equipment c. explain that an endotracheal tube will be needed d. let the child hear the sounds of an ECG monitor e. answer questions about surgery using words at the child's level of understanding

a. discuss postoperative discomfort and interventions b. show unfamiliar equipment d. let the child hear the sounds of an ECG monitor e. answer questions about surgery using words at the child's level of understanding

The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? a. ensure at least 11 hours of sleep b. do not put a TV in the child's bedroom c. select a day care center that provides physical activity opportunities every 4 hours d. limit 100% fruit juice to 6 ounces (180 mL) per day e. walk after the evening meal while the child rides a bike or skates

a. ensure at least 11 hours of sleep b. do not put a TV in the child's bedroom d. limit 100% fruit juice to 6 ounces (180 mL) per day e. walk after the evening meal while the child rides a bike or skates

A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? a. exercise b. follow a low protein diet c. wear low heeled shoes d. elevate legs above heart several times per day e. do not cross legs

a. exercise c. wear low heeled shoes d. elevate legs above heart several times per day e. do not cross legs

The nurse is talking with a new parent regarding activities that promote attachment between the parents and the newborn. What activities should the nurse include? a. feed baby on demand b. put baby in bed to sleep with parents c. allow baby to cry for at least 5 minutes d. sing to the baby e. stroke baby's face

a. feed baby on demand d. sing to the baby e. stroke baby's face

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? a. first Hep B vaccination b. second diphtheria vaccination c. third Hib vaccination d. influenza vaccination

a. first Hep B vaccination

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? a. frozen yogurt b. pudding c. hot cocoa in milk d. cheddar cheese e. watermelon

a. frozen yogurt b. pudding c. hot cocoa in milk d. cheddar cheese

What physical changes should the nurse discuss with a client who is entering menopause? a. loss of bone density b. loss of muscle mass c. improved skin elasticity d. a reduction in waist size e. increased fat tissue

a. loss of bone density b. loss of muscle mass e. increased fat tissue

Which clients will the healthcare provider discuss the treatment option of palliation? a. lung cancer, stage 4 with metastasis b. breast cancer, stage 1 c. testicular cancer, stage 1 d. colon cancer, stage 3 with metastasis e. ovarian cancer, stage 2

all of the above

The client who had spinal surgery 2 days ago shares with the nurse the inability to dorsiflex the right foot. What is the best comment the nurse can reply to the client? a. "Can you point your toes and foot down?" b. "Does your doctor know about this?" c. "It's probably due to the spinal anesthesia you had." d. "Think that happens a lot and should go away soon."

b. "Does your doctor know about this?"

Over which locations does the nurse auscultate breath sounds? a. trachea and lateral areas of thoracic cage b. anterior and posterior aspects of all lung fields c. the mid-section as well as the lateral section of the lungs d. the mid-clavicular to mid-axillary lines comparing side to side

b. anterior and posterior aspects of all lung fields

The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents? a. limit TV viewing and video game playing to 4 hours a day b. at least 60 minutes of moderate-intensity activity daily c. exercise should be structured d. a strict diet should be followed avoiding all junk food and drinking water only e. set a goal of at least 11,000 to 13,000 steps each day

b. at least 60 minutes of moderate-intensity activity daily e. set a goal of at least 11,000 to 13,000 steps each day

The nurse is evaluating a client for compliance to the prescribed diabetic program by checking recent lab results. Based on the lab data, what should the nurse conclude regarding the client? Fasting Blood Glucose: 90 mg/dL Hemoglobin A1C: 6.5% a. at risk for developing hypoglycemia b. demonstrating good control of blood glucose c. at risk for developing Somogyi phenomenon d. demonstrating signs of insulin resistance

b. demonstrating good control of blood glucose

What developmental milestone does the nurse expect to see in a two month old baby? a. responds to own name b. holds head up c. rolls over from stomach to back d. pushes down on legs when feet are on a hard surface e. turns head towards sound f. reaches for toy with one hand

b. holds head up e. turns head towards sound

What does a non-stress test tell the nurse about a pregnant client? a. that the baby is going to be a boy or girl b. the baby is doing well and the placenta is providing enough oxygen at this time c. that the baby's heart is healthy and there are no birth defects d. that the mother is strong enough to undergo vaginal delivery

b. the baby is doing well and the placenta is providing enough oxygen at this time

What should a nurse include when preparing to educate a female client on how to prevent recurrent cystitis? a. drink at least 8, 4 oz glasses of water per day b. urinate as soon as the urge occurs c. avoid irritating perineum with harsh soap d. empty your bladder post coitus e. avoid use of diaphragm

b. urinate as soon as the urge occurs c. avoid irritating perineum with harsh soap d. empty your bladder post coitus e. avoid use of diaphragm

A client has just found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected date of confinement? a. December 3 b. December 7 c. December 10 d. December 13

c. December 10

A client makes an initial visit to the prenatal clinic, informing nurse the probable date of conception was May 15th. The first day of the last menstrual cycle was on May 1st. Using Naegele's rule, the nurse determines the client's due date should be when? a. February 22nd b. August 8th c. February 8th d. August 22nd

c. February 8th

Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? a. has slight head lag when pulled to sitting position b. walks holding onto furniture c. able to sit, leaning forward on both hands d. has neat pincer grasp

c. able to sit, leaning forward on both hands

Which nursing action takes priority once a term infant has delivered vaginally? a. apply identification bands b. apply eye ointment c. dry the baby d. obtain footprints

c. dry the baby

The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? a. offer the client frequent high calorie snacks b. check the apical pulse before each dose c. perform or assist with oral hygiene every shift d. give the medication 30 minutes prior to meal

c. perform or assist with oral hygiene every shift

A client comes into the women's clinic with amenorrhea, breast tenderness, and urinary frequency. Which term should the nurse use to describe these signs/symptoms of pregnancy? a. probable b. positive c. presumptive d. early

c. presumptive

A nurse is providing education to client regarding the use of an inhaler for acute asthma symptoms. Which statement made by the client would indicate the need for further teaching? a. "I should shake the inhaler well before use." b. "I should breathe out slowly and completely through my mouth before placing the mouthpiece of the inhaler in my mouth." c. "I should hold my breath for approximately 8-10 seconds before exhaling slowly." d. "I should administer the two puffs that are ordered in rapid sequence."

d. "I should administer the two puffs that are ordered in rapid sequence."

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

d. "I try to provide whole grains, fruits, vegetables, and meat daily."

Which prevention strategy should the nurse consider when developing a health promotion plan for new parents concerning SIDS? a. place the infant in the prone position when placing the infant in the bed b. the child should sleep in a separate room from the parents c. the child should not have a pacifier in place when sleeping d. the child should be placed in the supine position when sleeping

d. the child should be placed in the supine position when sleeping

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children at 12 months? a. pertussis b. rotovirus c. tuberculosis d. varicella

d. varicella

A nurse is caring for a pediatric client who has been diagnosed with hypothyroidism. What is essential for the nurse to teach the parents of this child? a. administer the liquid medication with soy milk b. notify primary healthcare provider of slow heart rate c. monitor glucose before meals and at bedtime d. wait 4 hours after giving medication before giving iron supplements

d. wait 4 hours after giving medication before giving iron supplements

The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an IUD is most appropriate for what individuals? a. a mother of a toddler who wants another child in 3 years b. the client with a recent exacerbation of sickle cell anemia c. a client with stage II breast cancer who has finished chemotherapy d. an adolescent who has recently become sexually active e. the client with a double mastectomy 7 years ago

a. a mother of a toddler who wants another child in 3 years e. the client with a double mastectomy 7 years ago

A nurse plans to educate a group of new parents about how to prevent burn injuries in children. What should the nurse include? a. eliminate use of placemats b. establish "no" zones for space heaters c. cover unused electrical outlets d. warm baby bottle in microwave for 30 seconds e. set the hot water heater thermostat to 140F

a. eliminate use of placemats b. establish "no" zones for space heaters c. cover unused electrical outlets

A client diagnosed with cirrhosis is being treated for ascites and increased ammonia levels. Prior to discharge, the nurse reviews dietary instructions. The nurse knows teaching was successful when the client selects what menu plan? a. high calorie, low protein b. high protein, low sodium c. low calcium, low potassium d. low carbohydrates, high fat

a. high calorie, low protein

The nurse is performing a Denver Developmental Screening Test II on a 4.5 year old. What behavior should the nurse expect the child to demonstrate? a. prepares own cereal without help b. correctly copies a square c. draws a person with at least 5 body parts d. balances on each foot for more than 6 seconds

a. prepares own cereal without help

The nurse is checking a 9 month old's developmental status. What finding would be of concern to the nurse? a. unable to transfer a toy from one hand to the other hand b. cannot stand without support c. does not notice or mind when a parent leaves d. has not acquired a 6 word vocabulary

a. unable to transfer a toy from one hand to the other hand

The nurse is teaching a group of adults how to check skin lesions for signs of melanoma. What should the nurse include? a. symmetrical shape b. multiple colors with a lesion c. odd looking lesion d. poorly defined border of lesion e. diameter of lesion 6 mm

b, c, d, e

The nurse is completing the admission assessment on an elderly client newly arrived on the orthopedic unit. When asked about past medical history, the client indicates "some joint problems", but cannot provide further information. What further statement by the client suggests to the nurse the disease is likely rheumatoid arthritis? a. "My joints are really stiff and hurt every morning." b. "I have pain in my knees if I've been sitting a while." c. "I am better for a few months, but then get bad again." d. "My fingers hurt and the knuckles seem to get bigger."

c. "I am better for a few months, but then get bad again."

A client is 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? a. administer an antacid per standing orders b. check client's blood pressure c. call the primary healthcare provider immediately d. assure client this is a normal discomfort of pregnancy

c. call the primary healthcare provider immediately

An LPN is reinforcing education about fine motor skills to the caregivers of a school aged client. Which activity will the nurse suggest for this client? a. riding their bike without training wheels b. jumping rope twice daily c. learning to play the violin d. joining a local baseball team

c. learning to play the violin

At what age does the nurse expect to see a child build a tower of 9 blocks? a. one b. two c. three d. four

c. three

Which assessment by the nurse indicates a tension pneumothorax? a. sudden hypertension and bradycardia b. productive cough with yellow mucus c. tracheal deviation and dyspnea d. sudden development of profuse hemoptysis and weakness

c. tracheal deviation and dyspnea

A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? a. "I must keep both eyes covered till my check-up." b. "I should only have pain for about 2 days." c. "I will no longer have to wear reading glasses." d. "My vision will be blurry for a couple weeks."

d. "My vision will be blurry for a couple weeks."

The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? a. use small joints and muscles b. turn doorknobs clockwise c. sit in a chair that has a low, straight back d. push off with the palms of hands when getting out of bed e. use hairbrush with extended handle

d. push off with the palms of hands when getting out of bed e. use hairbrush with extended handle

The nurse is admitting an 8 month old infant to the pediatric unit. For what major developmental stressor in this infant should the nurse plan interventions? a. fear of unknown b. loss of daily routine c. body image disturbance d. separation anxiety

d. separation anxiety

The parents of a 1 month old report that their baby wakes up startled and stretches out the arms throughout the night. What suggestion should the nurse provide to the parents to decrease this reflex? a. rock to sleep b. place in a baby swing c. provide a pacifier d. swaddle the baby

d. swaddle the baby

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 lbs and is 5 ft 2 in tall. Determine the client's BMI to the nearest tenth?

24.7 Formula: BMI = (703 x weight in lbs) / (height in inches)^2

A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? a. blood pressure screening b. glucose monitoring c. influenza vaccination d. BMI calculation e. test urine for protein f. pneumococcal vaccination

a, b, c, d, e

An occupational health nurse works in a factory where loud equipment is used in production of the factory's product. What should the nurse emphasize to factory management persons to reduce the risk of hearing impairment? a. supply workers with earplugs when exposed to noise b. replace high noise machinery with low noise machinery c. limit amount of time a person spends at a noise source d. operate noisy machines during shifts when fewer people are exposed e. supply personal noise monitoring to identify employees at risk from hazardous level of noise f. have all employees make an appointment for a hearing test

a, b, c, d, e

What discharge education should a nurse provide to a client post hip replacement with a metal joint? a. weight bearing limits b. use of a high seated chair c. sexual intercourse in dependent position for up to 6 months d. avoid taking showers e. use of long handled tongs to assist with dressing

a, b, c, e

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? a. skipping breakfast will decrease energy level and could lower school grades b. freeze fruit before placing in lunch box to keep it tasting fresh c. limit snacks to when the child is hungry, rather than bored d. enforce rule that child must eat food even if they do not like it e. the parent should eat a variety of foods as an example to children f. prepare homemade healthy version of favorite take out meals

a, b, c, e, f

A client with type 2 diabetes, who is noncompliant, has a HbA1c of 8%. The finger stick blood sugar is 218 mg/dL at 0900. The current medications prescribed are metformin and exenatide. Based on this data, what teaching should the nurse reinforce? a. nutritional counseling to help improve diet compliance b. HbA1c measures glycemia control over a period of 1 month c. blood glucose testing d. HbA1c of 8% tells us that your average glucose level is 180 mg/dL e. without glycemic control, eye complications can occur

a, c, d, e

Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis? a. use a shower chair when performing hygiene b. limit alcohol intake c. stop any activity that causes dizziness d. limit daily sodium intake e. proper hand hygiene

a, c, d, e

A first time mother-to-be shares with the nurse a sense of indifference towards the impending birth of the infant. The client is concerned about "being a good mother" because of current lack of interest. What response by the nurse would be most appropriate at this time? a. "Such feelings do occur with some first time mothers." b. "Once you hold your new baby, you will be just fine." c. "Would you like to discuss this problem with the doctor?" d. "Describe the fears you have regarding your new baby."

a. "Such feelings do occur with some first time mothers."

A nurse has completed education on safe sexual practices to a group of college students. Which comments by the students would indicate that education has been successful? a. "The best way to prevent HIV is to abstain from sex." b. "Contraceptives should contain spermicide N-9." c. "Douching is recommended after intercourse." d. "Drinking too much alcohol can increase the risk of exposure to STDs." e. "If my partner will not use a condom, I will."

a. "The best way to prevent HIV is to abstain from sex." d. "Drinking too much alcohol can increase the risk of exposure to STDs." e. "If my partner will not use a condom, I will."

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? a. alcohol use b. dehydration c. diabetes d. exhaustion e. low level altitude

a. alcohol use b. dehydration c. diabetes d. exhaustion

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? a. apply ice to perineum for first 12 hours b. take sitz baths at temp of 107.6-111.2 F c. use witch hazel compresses on rectal areas for hemorrhoids d. take ibuprofen for pain e. apply topical anesthetics to perineal area f. avoid sexual intercourse until episiotomy has healed

a. apply ice to perineum for first 12 hours c. use witch hazel compresses on rectal areas for hemorrhoids d. take ibuprofen for pain e. apply topical anesthetics to perineal area f. avoid sexual intercourse until episiotomy has healed

The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems? a. birthweight less than 3 lbs, 4 oz (1.5 kg) b. gestational age 38 weeks c. chronic otitis media with effusion for more than 3 months d. lead level of 5.5 mg/dL 2 months ago e. mother with 8th grade education

a. birthweight less than 3 lbs, 4 oz (1.5 kg) c. chronic otitis media with effusion for more than 3 months d. lead level of 5.5 mg/dL 2 months ago e. mother with 8th grade education

The nurse is teaching a group of clients how to decrease the risk of developing osteoarthritis. What should the nurse include? a. control blood sugar b. use largest, strongest joints for lifting c. do intense aerobic exercise, daily d. maintain a healthy weight e. wear joint padding with playing sports

a. control blood sugar b. use largest, strongest joints for lifting d. maintain a healthy weight e. wear joint padding with playing sports

The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? a. discuss with healthcare provider your current exercise regimen and history b. you can continue any exercise that you have been doing before pregnancy c. if you haven't already started an exercise program, you should wait until after delivery d. exercise is required during pregnancy for a minimum of 15 minutes each day

a. discuss with healthcare provider your current exercise regimen and history

The pediatric clinic nurse is teaching the mother of an infant about measures for prevention of RSV infection. What information does the nurse correctly identify? a. frequent hand washing b. clean and disinfect surfaces, including toys c. avoid close contact with anyone who has cold or flu-like symptoms d. avoid kissing your baby during RSV season e. avoid crowded day care during the infant's first winter season

a. frequent hand washing b. clean and disinfect surfaces, including toys c. avoid close contact with anyone who has cold or flu-like symptoms e. avoid crowded day care during the infant's first winter season

A pediatric nurse is providing anticipatory guidance to a group of parents who have children nearing the age of 1 year old. What milestones should the nurse teach the parents to expect to see in their 1 year old child? a. gets to a standing position without help b. puts out arm or leg to help with dressing c. able to say several single words d. pulls toys while walking e. builds a tower of 4 blocks

a. gets to a standing position without help b. puts out arm or leg to help with dressing

What strategies for smoking prevention could the school nurse recommend to the community task force? a. have a "Pledge Campaign" asking students not to use tobacco b. include effects of smoking in health classes c. enlist help from celebrities who are against smoking d. conduct a "Don't Smoke" poster contest aimed at seventh graders e. start a smoking cessation class for students who currently smoke

a. have a "Pledge Campaign" asking students not to use tobacco b. include effects of smoking in health classes c. enlist help from celebrities who are against smoking d. conduct a "Don't Smoke" poster contest aimed at seventh graders

A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? a. holds baby face to face b. talks about the baby's features c. touches baby frequently d. talks to baby e. allows baby to cry vigorously for 15 minutes

a. holds baby face to face b. talks about the baby's features c. touches baby frequently d. talks to baby

A home care nurse is completing an initial assessment on an elderly client living alone. What normal effects of aging would the nurse expect to find? a. loss of skin elasticity b. decline in sensory system c. decreased enjoyment of intimacy d. forgetfulness e. desire to remain at home

a. loss of skin elasticity b. decline in sensory system

A 19 year old client preparing to enter college asks the clinic nurse about immunizations. What immunizations should the nurse suggest the client discuss with the primary healthcare provider? a. meningococcal conjugate vaccine b. Tdap vaccine c. HPV vaccine d. seasonal flu vaccine e. hepatitis B f. polio

a. meningococcal conjugate vaccine b. Tdap vaccine c. HPV vaccine d. seasonal flu vaccine e. hepatitis B

A nurse is planning to conduct primary prevention classes in a local community. Which initiatives should the nurse include? a. parenting classes for first time parents b. healthy diet classes for school-age children c. breast self-examination classes d. cardiac rehabilitation classes e. community exercise classes to promote weight loss

a. parenting classes for first time parents b. healthy diet classes for school-age children d. community exercise classes to promote weight loss

The nurse is instructing the mother of a toddler diagnosed with cystic fibrosis (CF) about specific dietary modifications the child will need. The nurse knows the teaching is successful when the mother selects what foods? SATA a. potato chips b. low-fat yogurt c. salt-free bacon d. hot dog on a bun e. fresh avocados f. macaroni and cheese

a. potato chips d. hot dog on a bun e. fresh avocados f. macaroni and cheese

A nurse is planning to conduct parenting classes for first time parents in an attempt to decrease child abuse in the community. What type of prevention is the nurse utilizing? a. primary prevention b. secondary prevention c. tertiary prevention d. case management

a. primary prevention

What term should the nurse use to document that a woman is pregnant for the first time? a. primigravida b. multigravida c. primipara d. multipara

a. primigravida

The nurse is teaching a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include? a. promote a diet rich in fruits and vegetables b. provide instruction on benefits of carotid endarterectomy c. limit sodium intake to 2 g/day d. engage in low intensity exercise once a week e. avoid tobacco products f. decrease alcohol consumption to 2 drinks per day

a. promote a diet rich in fruits and vegetables c. limit sodium intake to 2 g/day e. avoid tobacco products f. decrease alcohol consumption to 2 drinks per day

The nurse is planning care for a preschool child who is being treated in the hospital for RSV. What should the nurse recognize as the child's likely view of this illness in order to properly plan care? a. punishment b. disturbed body image c. rejection from parents d. change in routine with friends

a. punishment

A client who has recurrent episodes of allergic rhinitis asks the nurse what could be done to decrease symptoms. What instruction should the nurse provide to this client? a. remove pets from interior of home b. treat a stuffy nose with warm salt water c. remove carpeting d. stay inside when pollen count is at its lowest e. wash bed linens in hot water

a. remove pets from interior of home b. treat a stuffy nose with warm salt water c. remove carpeting e. wash bed linens in hot water

The homecare nurse is instructing a client with COPD about the importance of a nutritious diet to avoid weight loss. The nurse knows that teaching has been effective when the client selects which foods for a breakfast menu? a. scrambled eggs b. cheese omelet c. sliced banana d. orange juice e. dry toast

a. scrambled eggs b. cheese omelet c. sliced banana d. orange juice

A community health nurse, participating in a health fair, is educating a community group about risk factors for developing varicose veins. What risk factors should the nurse include? a. sitting for prolonged periods b. obesity c. female d. leg exercises e. wearing high-heeled shoes

a. sitting for prolonged periods b. obesity c. female e. wearing high-heeled shoes

What risk factors should the nurse include when teaching a group of clients about osteoarthritis? a. sports injury to joint b. genetic predisposition c. obesity d. male sex e. repetitive joint stress

a. sports injury to joint b. genetic predisposition c. obesity e. repetitive joint stress

The nurse is caring for a client admitted with Graves' Disease. Which area of Graves' Disease would the nurse teach the client? a. the peak age of diagnosis is between ages 40-60 b. Graves' is 7-8 times more likely to affect men than women c. Graves' disease is the #1 cause of hyperthyroidism d. this can happen when people taking thyroid hormone supplements (hypothyroidism or underactive thyroid) take too few of them e. people with Graves' disease usually have too much T3 and T4 in their blood

a. the peak age of diagnosis is between ages 40-60 c. Graves' disease is the #1 cause of hyperthyroidism e. people with Graves' disease usually have too much T3 and T4 in their blood

A client comes into the ED with intense abdominal pain. The nurse completes a physical assessment and evaluates the vital signs and lab work. Based on the information gathered, the nurse expects which diagnostic test will be priority? Nursing Note: 16 year old female admitted to treatment room 3, reporting "intense abdominal pain" at 10/10. States, "pain started 3 days ago, but got worse this morning." Confirms no injury to abdominal area. Rigid, board-like abdomen noted. Last menstrual cycle "6 weeks ago." Lab work: hemoglobin 10 g/dL hematocrit 32% serum hCG 27 a. transvaginal ultrasound b. esophagogastroduodenoscopy (EGD) c. CAT scan of the abdomen d. KUB

a. transvaginal ultrasound

A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? a. turn the client to the left side b. administer oxygen c. start an intravenous line d. prep the mother for cesarian section e. notify the primary healthcare provider

a. turn the client to the left side b. administer oxygen e. notify the primary healthcare provider

Which clients should the nurse recommend receive the HPV vaccine? a. twelve year old male b. eight year old female c. twenty-five year old bisexual male d. twenty-two year old female with compromised immune system e. twenty-nine year old male who has not received the HPV vaccine

a. twelve year old male c. twenty-five year old bisexual male d. twenty-two year old female with compromised immune system

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? a. type 2 diabetes mellitus b. hypertension c. hispanic ethnicity d. atrial fibrillation e. sleep apnea f. smoking

a. type 2 diabetes mellitus b. hypertension d. atrial fibrillation e. sleep apnea f. smoking

The nurse is sharing best practice for preventing pressure injuries in clients. What should the nurse include? a. use moisturizer daily on dry skin b. massage reddened skin areas c. prevent shearing by maintaining the head of bed at 45 degrees or higher d. place rubber ring (donut) under client's sacral area e. position client at 30 degree tilt when placed on side

a. use moisturizer daily on dry skin e. position client at 30 degree tilt when placed on side

The nurse has been working with an attractive teenage girl regarding appropriate nutrition. Which statement by the teenager would support a disturbed body image and the need for education on adequate nutrition? a. "I am happy my weight is within normal limits." b. "I can never exercise enough to lose those saddle bags." c. "I must always work harder on school work and hobbies." d. "I try to eat only 2 meals a day to keep my weight down." e. "I have been trying to include more fruits and vegetables in my diet."

b, c, d

What teaching points should the nurse include when educating a client how to prevent a venous stasis ulcer? a. elevate legs above heart for 5 minutes, twice a day b. perform leg exercises regularly c. wear graduated compression stockings d. treat itching with prescribed topical corticosteroids e. minimize stationary standing

b, c, d, e

A client from Indonesia is being admitted to the Labor and Delivery unit. Her spouse brought her to the hospital. She is 39 weeks gestation, her contractions are 4 minutes apart, and she experienced spontaneous rupture of membranes at home. She does not speak English, but a hospital-based interpreter is present. Which questions by the nurse would be appropriate to ask the client when performing the admission assessment? a. Are there any odd cultural practices that we need to be aware of in caring for you during labor and delivery? b. In your culture, are fathers generally present for the delivery? c. Are there any foods that are not permitted or are requested based on your culture or religion? d. Do you have any personal beliefs or customs prohibiting physical activity during pregnancy, birth, and the postpartum period that you will be observing? e. Will you be observing any special or culturally accepted way for expression of pain? f. Are there any special considerations that need to be observed for newborn care?

b, c, d, e, f

A nurse has taught a group of teenage girls about breast self-awareness. Which statements by the teens would indicate to the nurse that teaching was effective? a. "I should have a clinical breast exam every 5 years starting at the age of 18." b. "Doing a monthly breast self-exam will help me learn what is normal for me." c. "It is only important to know my maternal health history." d. "Signs I should not ignore include dimpling of the skin and nipple discharge." e. "Self-breast exam should be done a few days before my menstrual cycle begins."

b. "Doing a monthly breast self-exam will help me learn what is normal for me." d. "Signs I should not ignore include dimpling of the skin and nipple discharge."

A nurse has provided postpartum discharge instructions to a client who had a cesarean section. What statement by the client would indicate to the nurse that further teaching is necessary? a. "I will relax and contract my pelvic floor muscles 10 times, 8 times a day." b. "Driving is permitted in one week if I am pain free." c. "Lifting anything heavier than my baby is not advised." d. "I will not cross my legs while sitting."

b. "Driving is permitted in one week if I am pain free."

Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? a. "I want to make my mark on the world." b. "I am satisfied with my life so far." c. "I wish I could go back and fix the mistakes I have made." d. "Life is too short. I have more living to do."

b. "I am satisfied with my life so far."

A client has received discharge education post cataract surgery. Which statement made by the client indicates to the nurse that further teaching is needed? a. "A protective eye patch or shield as prescribed." b. "I will notify my primary healthcare provider for any amount of discharge, redness, or scratchy feeling because these symptoms are abnormal." c. "I will clean the surgical eye with a clean tissue, wiping once from the inner aspect of the closed eye to the outer eye." d. "When sleeping, I will avoid lying on the same side of my affected eye."

b. "I will notify my primary healthcare provider for any amount of discharge, redness, or scratchy feeling because these symptoms are abnormal."

A primigravida asks the nurse about the purpose of the RhoGam injection. What would be the best explanation by the nurse? a. RhoGam changes the Rh positive fetus to Rh negative b. RhoGam prevents the mother from forming Rh antibodies c. RhoGam inhibits Rh antibodies in the newborn infant d. RhoGam destroys antibodies in the Rh positive mother

b. RhoGam prevents the mother from forming Rh antibodies

The nurse is teaching a group of teenagers about decreasing the risk of developing skin cancer. What information should the nurse include? a. use sunscreen with a SPF of at least 10 b. a self-tanning product containing DHA is safe to use c. put on sunscreen every day, even on days when it is cloudy d. stay in the shade between 9 am and 4 pm e. tanning beds are safer than outdoor tanning

b. a self-tanning product containing DHA is safe to use c. put on sunscreen every day, even on days when it is cloudy d. stay in the shade between 9 am and 4 pm

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past 3 days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? a. suggest that the family seek an appointment with the primary healthcare provider b. ask the dietician to visit the client and discuss food preferences c. note any weight loss over the next month d. continue to monitor intake over the next couple of weeks

b. ask the dietician to visit the client and discuss food preferences

The nurse is talking with a group of teenagers who have expressed an interest in getting a tattoo. What information about tattoos should the nurse provide? a. apply a moisturizer to the tattooed skin once a day b. carefully consider the tattoo location as weight gain can distort the image c. bloodborne risks of tattooing include Hepatitis and HIV d. tattoo dyes can cause allergic skin reactions e. tattoos can be inexpensively removed with little discomfort f. make sure the tattoo artist removes the needle and tubes from sealed packages

b. carefully consider the tattoo location as weight gain can distort the image c. bloodborne risks of tattooing include Hepatitis and HIV d. tattoo dyes can cause allergic skin reactions f. make sure the tattoo artist removes the needle and tubes from sealed packages

A nurse is teaching a group of women about HPV. What should the nurse tell the women the HPV puts women at risk for? a. human immunodeficiency virus b. cervical cancer c. hepatitis B d. cirrhosis

b. cervical cancer

What characteristics would indicate to the obstetrical nurse that a client is experiencing false labor? a. cervical dilation noted b. contractions decrease with sleep c. bloody show noted d. contraction intensity increases with walking e. contractions felt in abdomen above umbilicus

b. contractions decrease with sleep e. contractions felt in abdomen above umbilicus

The nurse is checking a 2 month old's developmental status. What finding would be of concern to the nurse? a. not able to hold head steady b. does not bring hands to mouth c. not able to roll over in either direction d. does not push down with legs when feet are placed on a hard surface

b. does not bring hands to mouth

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

b. establishes a routine of 30 minutes of brisk walking 3 days per week

The nurse is discussing appropriate toys for toddlers with a group of parents. What toys should the nurse include? a. board games b. finger paint c. swing set d. water squirting toys e. play telephone f. wooden spoons

b. finger paint d. water squirting toys e. play telephone f. wooden spoons

Following report, which newborn infant should the nursery nurse assess first? a. positive Babinski reflex noted b. has circumoral cyanosis c. negative Ortolani's sign noted d. has telangiectatic nevi

b. has circumoral cyanosis

What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? a. smokeless tobacco increases risk for lung cancer b. inspect mouth frequently for lesions c. white patches in mouth should be reported to healthcare provider d. risk for stomach cancer can be decreased by not swallowing smokeless tobacco juice e. report decreased saliva to primary healthcare provider f. smoking cessation

b. inspect mouth frequently for lesions c. white patches in mouth should be reported to healthcare provider f. smoking cessation

A nurse is participating in a cancer risk screening program. Which signs/symptoms would indicate to the nurse that a client needs further investigation? a. unexplained weight gain of 10 lbs b. leukoplakia c. prolonged hoarseness d. hematuria e. persistent abdominal bloating

b. leukoplakia c. prolonged hoarseness d. hematuria e. persistent abdominal bloating

The nurse is reviewing the CDC's guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? a. rotavirus b. meningococcal c. herpes zoster d. seasonal influenza e. human papilloma virus

b. meningococcal d. seasonal influenza e. human papilloma virus

A nurse is caring for a multipara client in active labor who has administered 4 mg of morphine for pain. Thirty minutes later, the client had a precipitous delivery. What should the nurse prepare to administer to the newborn? a. oxygen b. naloxone c. glucose d. vitamin K

b. naloxone

A female client arrives at the community health clinic seeking a form of contraceptive and tells the nurse that she really desires getting an IUD. Following the assessment, the nurse realizes that the IUD would be contraindicated for this client. What factor would be an absolute contraindication for this client receiving an IUD? a. history of irregular menstrual cycles b. ongoing pelvic infection c. history of an ectopic pregnancy d. current fibrocystic breast disease

b. ongoing pelvic infection

A nurse notes late decelerations in the fetus of a client who is receiving oxytocin via IV infusion. What nursing interventions should the nurse perform? a. administer naloxone b. place client in side-lying position c. stop oxytocin d. increase the rate of IV fluids e. notify primary healthcare provider f. administer oxygen at 8 L/min per face mask

b. place client in side-lying position c. stop oxytocin d. increase the rate of IV fluids e. notify primary healthcare provider f. administer oxygen at 8 L/min per face mask

Which nursing intervention represents secondary prevention level? a. teaching the effects of alcohol to elementary school children b. providing care for abused women in a shelter c. leading a group of adolescents in drug rehabilitation d. ensuring medication compliance in a client with schizhophrenia

b. providing care for abused women in a shelter

A client has been trying to implement a low fat diet for prevention of heart disease and enhancement of weight loss. He further reports that his wife shows her love by preparing rich foods and pastries. Which action should the nurse make? a. suggest that the client prepare all meals at home b. schedule a meeting with husband and wife to discuss diet and health c. suggest that the client limit intake to one serving of each food at meals d. ask the client to give his wife a cookbook with low fat recipes

b. schedule a meeting with husband and wife to discuss diet and health

The nurse is working on health promotion plans for a small group of school-aged children who are at risk for obesity. Which baseline data would support the risk for obesity? a. spends one hour playing sports or swimming daily b. spends at least 2 hours watching TV after dinner each day c. assists mom in preparing low carb snacks for the family d. participates in the marching band at school

b. spends at least 2 hours watching TV after dinner each day

The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? a. design a booklet for school districts on handling aggression b. survey students to determine attitudes towards weapons c. provide information on anger management to grade schools d. investigate existing safety procedures in the schools

b. survey students to determine attitudes towards weapons

A nurse is participating in a community health fair for middle aged individuals. Which points should the nurse stress for decreasing the risk of stroke? a. reduce dietary intake of unsaturated fat b. swim or walk most days of the week c. treat obstructive sleep apnea, if present d. drink 5 or more 8 ounce glasses of water daily e. decrease smoking to less than 1/2 pack a day

b. swim or walk most days of the week c. treat obstructive sleep apnea, if present d. drink 5 or more 8 ounce glasses of water daily

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

b. the developmental task at this stage is adjusting to the needs of more than two family members

What information would be included when a disaster relief nurse counsels parents of young clients who have experienced a disaster? a. act as if things are normal b. understand young children may exhibit separation fears and clinging c. sedate the client until the crisis is resolved d. understand nightmares and sleep disturbances may occur in young children e. refrain from talking about the disaster

b. understand young children may exhibit separation fears and clinging d. understand nightmares and sleep disturbances may occur in young children

What information would the nurse include when participating in community health training about STIs? a. clients are screened for chlamydial infection and/or gonorrhea only if the client is experiencing cervical discharge, dyspareunia, and dysuria b. women with chlamydial infection or gonorrhea are likely to be asymptomatic c. in many instances, chlamydia infection and/or gonorrhea will go away without intervention d. it is only necessary for females to be treated for chlamydial infections and/or gonorrhea due to the potential damage to a female's reproductive system

b. women with chlamydial infection or gonorrhea are likely to be asymptomatic

The nurse asks the UAP why she is crying in the hallway. The UAP states, "That client in room 107 is so mean. No matter what I say they just yell at me." Which is the best response by the nurse? a. "That client is like that to everyone. He will be discharged soon." b. "Just don't go back in the room the rest of your shift." c. "I know you are upset. You are trying to provide care to them." d. "Let's go tell the charge nurse to fix this problem."

c. "I know you are upset. You are trying to provide care to them."

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

c. be aware that ovulation may not occur for many months after using medroxyprogesterone acetate

A client arrives on the orthopedic unit following an open reduction-internal fixation (ORIF) of a fractured femur. Following the initial assessment, the nurse offers pain medication. The client refuses, indicating a preference to control personal pain with meditation. What observations by the nurse would indicate this method has been successful in controlling the client's post-op pain? a. client shuts eyes tight when leg repositioned b. client is restless c. client vitals are at baseline during activity d. client is able to sleep 3-4 hours during the night

c. client vitals are at baseline during activity

A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is most appropriate at this time? a. lie on left side and take slow, deep breaths b. call an ambulance and go to emergency room c. come to the clinic for assessment and evaluation d. go directly to the hospital emergency room

c. come to the clinic for assessment and evaluation

A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse initiate? a. instruct the child to extend the affected knee b. perform range of motion exercise on both knees c. compare the appearance of the left knee to the right knee d. have the child soak the affected knee in warm water

c. compare the appearance of the left knee to the right knee

A nurse is caring for an 80 year old client with a total hip arthroplasty (THA) 8 hours ago. Which nursing postoperative intervention has priority for an elderly client. a. reorient to time and place b. position in an abduction pillow c. coughing and deep breathing exercises Q2H d. turn the client toward the unaffected side

c. coughing and deep breathing exercises Q2H

What should the nurse emphasize when teaching clients how to decrease the risk of chronic obstructive pulmonary disease? a. avoid exposure to individuals with respiratory infections b. increase intake of Vitamin C c. eliminate exposure to secondhand smoke d. avoid prolonged exposure to occupational dusts and chemicals e. get a yearly influenza and pneumococcal vaccination

c. eliminate exposure to secondhand smoke d. avoid prolonged exposure to occupational dusts and chemicals

What should the nurse teach a client about testicular self examination? a. this exam should be performed bi-annually b. the exam should be performed during a cold shower c. gently roll each testicle with slight pressure between the fingers d. the epididymis should feel like a hard, knotty rope

c. gently roll each testicle with slight pressure between the fingers

A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? a. rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures b. rubella is the most common cause of meningitis and acquired deafness c. if a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect d. rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis, or meningitis and can lead to death

c. if a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect

The parents of a toddler ask the nurse how to stop their child's temper tantrums when they occur. What is the best advice the nurse should provide? a. spank the child gently when the tantrum occurs b. promise the child a new toy if the child stops the tantrum c. ignore the tantrum if the child is safe d. restrain the child during a tantrum

c. ignore the tantrum if the child is safe

A female client considers using spermicidal agents because she wants birth control and protection from STIs. What information should the nurse provide the client about spermicidal agents? a. effectively reduces vaginal fungal infections such as Candida albicans b. eliminates bacterial and viral STIs c. most effective when used in conjunction with barrier methods, such as a diaphragm d. causes few side effects

c. most effective when used in conjunction with barrier methods, such as a diaphragm

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? a. test serum glucose values monthly b. avoid starches and sugars in the diet c. obtain a normal body weight and exercise regularly d. maintain a normal serum lipid panel

c. obtain a normal body weight and exercise regularly

During a health fair, a client asks the nurse about the methods used to detect prostate cancer. What should the nurse tell the client about the detection process? a. abdominal x-rays to detect the presence of lesions and masses b. a serum calcium test to detect elevated levels, which may indicate bone metastasis c. prostate-specific antigen (PSA) test to evaluate the prostate d. a magnetic resonance image (MRI) study to detect tumors and other abnormal growths

c. prostate-specific antigen (PSA) test to evaluate the prostate

A homecare nurse is attempting to visit clients isolated during a pandemic. Upon arriving at one small rural home, the nurse discovers the client is almost out of food, has no wood for heating, and has a broken water faucet. The client is alert, oriented, and refuses to leave the home. There is no family to help the client. How could the nurse best assist the client to remain home at this time> a. call local ambulance crew to transport client to the hospital b. ask the healthcare provider to order emergency placement c. request immediate evaluation by senior protective services d. run to the local store to obtain food and water for the client e. develop a plan of care with client, based on present needs

c. request immediate evaluation by senior protective services e. develop a plan of care with client, based on present needs

The nurse has initiated instruction for an 11 year old child newly diagnosed with diabetes mellitus. The child indicates anxiety about the need for daily insulin injections. What nursing action would best address this issue? a. tell the child it only hurts for a moment b. have the parents administer the shots c. show the child how to give self injections d. provide toy syringe for the client to play with

c. show the child how to give self injections

The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would most likely be based on what? a. an inappropriate desire for youthfulness and staying young b. the decision to never marry c. the lack of a sense of wholeness, purpose, and a life well lived d. the fear of experiencing a painful death

c. the lack of a sense of wholeness, purpose, and a life well lived

The nurse is assessing a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time? a. blood glucose level b. ankles for edema c. twenty-four hour diet recall d. confirmation of last menstrual period

c. twenty-four hour diet recall

A new nurse on a telemetry unit has been assigned a client admitted for treatment of congestive heart failure. When completing a cardiac output assessment, the nurse would evaluate what body function? a. skin turgor b. bowel sounds c. urinary output d. pupillary reaction e. peripheral edema f. level of consciousness

c. urinary output e. peripheral edema f. level of consciousness

The nurse is providing care to an elderly widow recovering from surgical repair of a fractured hip. The client had been teaching school, but now fears the school district may use this injury to force retirement. The client indicates anxiety about not working and being bored. What statement by the nurse would be most therapeutic at this time? a. "You should enjoy sleeping in and much quieter days." b. "Don't you have friends or hobbies you would enjoy?" c. "Maybe you could just look for another job to do." d. "What part of being retired concerns you most?"

d. "What part of being retired concerns you most?"

A pregnant woman who has just been admitted to the labor and delivery room states that her "water just broke." What should the nurse do immediately? a. confirm that fluid is amniotic fluid with a pH test strip b. obtain maternal vital signs c. observe amniotic fluid color d. check fetal heart rate (FHR) pattern

d. check fetal heart rate (FHR) pattern

What discharge instructions should the nurse provide to the parents of a child diagnosed with sickle cell anemia? a. provide high-calorie, low protein diet b. inheritance is by autosomal dominate genes c. restrict all activities for 3 months d. deferasirox helps prevent liver damage from iron deposits e. avoid high altitudes

d. deferasirox helps prevent liver damage from iron deposits e. avoid high altitudes

The nurse is checking a two year old's developmental status. What finding would be of concern to the nurse? a. unable to use "me" and "you" correctly b. has trouble focusing on one activity for more than 5 minutes c. does not follow a 3-part command d. does not know what to do with a spoon

d. does not know what to do with a spoon

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen, and is on bedrest. What is the most important assessment at this time? a. protein in the urine b. fetal heart tones c. cervical dilation d. hemoglobin and hematocrit levels

d. hemoglobin and hematocrit levels

A client with a history of syncope and transient arrhythmias has been ordered a Holter monitor for 48 hours. The nurse knows that teaching has been effective when the client makes what statement? a. no follow up care will be needed after the monitor is removed b. it is okay to shower or bathe while wearing this equipment c. I have to take it easy and not exercise for the next two days d. it's important to write down all my activities during this time

d. it's important to write down all my activities during this time

Which intervention should the nurse recommend to the adult child who is caring for an elderly patient diagnosed with Alzheimer's disease? a. give parent a small dog for company and comfort b. reset the water heater to 125 degrees to prevent burns c. place mirrors in multiple locations so parent sees images of self d. make floors and walls different colors

d. make floors and walls different colors

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? a. ambulate in the room b. perform crede' exercises c. reassess the fundus in 30 minutes d. massage the fundus

d. massage the fundus

What is the priority nursing action for a pregnant client in labor who is having an epidural catheter inserted for pain management? a. perform a thorough skin prep of the insertion site b. obtain the client's consent for the procedure c. assure the client that residual effects of the procedure won't be felt d. monitor maternal blood pressure

d. monitor maternal blood pressure

A client 34 weeks pregnant is schedule for a visit at the prenatal clinic one week after receiving an injection of prenatal betamethasone due to the potential for premature labor. The client had been resting at home all week, as ordered. What assessment finding by the nurse should be reports to the primary healthcare provider immediately? a. blood pressure of 92/50 b. fasting blood sugar of 75 c. tympanic temp of 100F d. muscle weakness with cramping

d. muscle weakness with cramping

The parents of a nine month old ask the nurse for toy recommendations. What recommendation should the nurse make? a. mobile b. tricycle c. marbles d. pull toy

d. pull toy