Med surg II

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu?

Raspberry juice Rationale: A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

A nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure?

Limit caffeine intake. Rationale Excessive caffeine intake can increase calcium loss in the urine. Protein deficiency may contribute to the incidence of bone demineralization. Activities such as walking and swimming may be beneficial and are appropriate to reduce the risk of fracture. Adequate vitamin D intake is necessary for the metabolism of calcium.

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps?

"Bend your foot toward your body while extending the knee when the cramps occur."

The community health nurse is providing a session to community members about the risks associated with laryngeal cancer. Which statement by a person attending the session indicates correct understanding of the risk factors?

"Exposure to airborne carcinogens can cause this type of cancer." Rationale: To decrease the risk of laryngeal cancer, the client should be instructed to avoid cigarette smoking, alcohol consumption, exposure to airborne carcinogens, and vocal abuse. The client is instructed to schedule routine physical examinations. The client also should be instructed to seek medical care if difficulty in swallowing, persistent hoarseness, enlarged lymph nodes in the neck, or unexplained weight loss occurs.

Rationale: A child with HIV infection will receive the same immunizations as other children except for live vaccines. All household members receive the influenza vaccine. Option 4 is not necessary and is inaccurate.

"Family members in the household need to receive the influenza vaccine." Rationale: A child with HIV infection will receive the same immunizations as other children except for live vaccines. All household members receive the influenza vaccine. Option 4 is not necessary and is inaccurate.

The nurse is providing instructions to the mother of a child with human immunodeficiency virus (HIV) infection regarding immunizations. Which statement by the mother indicates an understanding of the immunization schedule?

"Family members in the household need to receive the influenza vaccine." Rationale: A child with HIV infection will receive the same immunizations as other children except for live vaccines. All household members receive the influenza vaccine. Option 4 is not necessary and is inaccurate.

A nurse monitoring an oncological client assesses for which early sign of vena cava syndrome?

1.Cyanosis 2.Arm edema 3.Periorbital edema # 4.Mental status changes Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

The nurse is providing a dietary session to a group of clients about the vitamin content of various foods. The nurse should tell the clients that which food item is highest in vitamin A?

1.Eggs 2.Milk 3.Tomatoes 4.Green leafy vegetables # Rationale: Green leafy vegetables are a good source of vitamin A, whereas milk is high in vitamin D content. Eggs are high in vitamin B complex, and tomatoes are high in vitamin C.

A 27-year-old female client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask her whether the breast lumps seem to become more prominent or troublesome at which time?

1.After menses 2.Before menses # 3.During menses 4.At any time, regardless of the menstrual cycle Rationale: The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes.

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?

1.Crusting # 2.Wrinkling 3.Deepening of expression lines 4.Thinning and loss of elasticity in the skin Rationale: The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin would indicate a potential complication.

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy?

Hairdressers Rationale: Individuals most at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry, or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

My contractions will increase in duration and intensity." Rationale: True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response?

"At this age, the child is developing his own personality." Rationale: According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents.

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions?

"I should wear knee-high hose, but I should not leave them on longer than 8 hours." Rationale: Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and to minimize falls.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions?

"If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider." Rationale: Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the HCP. Options 1, 2, and 3 are normal changes that occur in the postpartum period.

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction?

"It is best to do TSE first thing in the morning before a bath or shower." Rationale: TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand . It is best to perform the exam during or after a warm shower or bath when the scrotum is most relaxed.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence." Rationale: Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.

A client with an endocrine disorder complains of weight loss and diarrhea, and says that he can "feel his heart beating in his chest." The nurse interprets that which gland is most likely responsible for these symptoms?

1.Thyroid # 2.Pituitary 3.Parathyroid 4.Adrenal cortex Rationale: The thyroid gland is responsible for a number of metabolic functions in the body, including metabolism of nutrients (such as fats and carbohydrates). Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. Thus, a client with increased activity of the thyroid gland exhibits weight loss from higher metabolic rate and increased pulse rate.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal?

Pale straw-colored, with flecks of vernix. Rationale: Amniotic fluid normally is pale straw-colored and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L Rationale: The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L. A serum potassium level lower than 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

With which age group should the nurse use "magical thinking" as a developmental strategy when administering medications?

Preschool Rationale: The nurse uses developmental perspectives when administering medications. The preschool age is when the nurse can make use of "magical thinking" as a strategy to administer medications. Infants and toddlers are too young for this concept, and school-age children are too mature.

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment as an abnormal finding?

Presence of fasciculations Rationale: Fasciculations are fine muscle twitches that normally are not present. Muscle strength is graded from 0/5 (paralysis) to 5/5 (normal power). Symmetrical muscle movement is a normal finding. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal.

The clinic nurse assesses the communication patterns of a 5-month-old infant. Which assessment finding should lead the nurse to determine that the infant is demonstrating the highest level of developmental achievement expected?

Uses monosyllabic babbling Rationale: Using monosyllabic babbling occurs between 3 and 6 months of age. Cooing begins at birth and continues until 2 months of age. Linking syllables together when communicating occurs between 6 and 9 months of age. Using simple words such as mama occurs between 9 and 12 months of age.

A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit?

Bananas Rationale: Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, fresh oranges, mangos, nectarines, papayas, and prunes

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make?

Between 16 and 20 weeks Rationale: Fetal movement, called quickening, is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements that gradually increase in intensity.

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?

Breast-feeding Rationale: Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. The other options are incorrect.

A client who visits the health care provider's office for a routine physical reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse should check for which manifestations?

Complaints of weakness and lethargy Rationale: Weakness and lethargy are common complaints associated with hypothyroidism. Other common symptoms include weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid?

Green leafy vegetables Rationale: Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Pork, cheese, and chicken are not high in folic acid. Pork is a good source of thiamine. Cheese is a dairy product and is high in calcium. Chicken is a good source of protein.

A nurse provides teaching regarding how to relieve discomfort to a client in her second trimester of pregnancy that is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching?

"When I get home I should lie on the floor, with my legs elevated onto a couch, and turn my hips and knees at right angles." Rationale: Lying on the floor with the legs elevated onto a couch with the hips and knees at right angles will produce a posture of pelvic tilt while countering gravity, which is the force that leads to edema of the lower extremities. Although the other options might seem useful, remember that heat needs to be prescribed by a health care provider (HCP). Lying on the left side with the feet dorsiflexed may help with the reduction of hemorrhoids.

A client with heart disease is provided instructions regarding a low-fat diet. The nurse should determine that the client understands the diet if the client states that which food item should be avoided?

1.Apples 2.Oranges 3.Cherries 4.Avocados # Rationale: Fruits and vegetables, except avocados, olives, and coconuts, contain minimal amounts of fat.

The nurse is teaching a group of adults about the warning signs of cancer. Which signs should the nurse provide to the group? Select all that apply.

1.Areas of alopecia 2.Sores that do not heal # 3.Nagging cough or hoarseness # 4.Indigestion or difficulty swallowing # 5.Change in bowel or bladder habits # 6.Absence or decreased frequency of menses Rationale: Cancer is a neoplastic disorder that can involve all body systems. In cancer, cells lose their normal growth-controlling mechanism. Some signs include sores that do not heal, a nagging cough or hoarseness, indigestion or difficulty swallowing, and a change in bowel or bladder habits. Areas of alopecia occur following cancer chemotherapy. Absence of menses is not a specific sign; however, abnormal occurrence of menses may be.

The nurse is providing instructions to a client with kidney disease about a low-protein diet. The client demonstrates understanding of the dietary instructions by stating the need to limit which food from the diet?

1.Chicken # 2.Whole milk 3.Swiss cheese 4.Peanut butter Rationale: Chicken (3 ounces) contains 26 g of protein, and peanut butter (2 tablespoons) contains 9 g of protein. Whole milk (1 cup) contains 8 g of protein, and Swiss cheese (1 ounce) contains 7 g of protein.

A nurse working in an infertility clinic reviews the medical history of a 35-year-old woman who is currently taking fertility medications and is planning a pregnancy. Which medication, if present in the client's history, would indicate a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate?

1.Methyldopa 2.Folic acid (Folvite) 3.Phenytoin (Dilantin) 4.Bupropion (Wellbutrin SR) Rationale: An antiseizure medication (specifically phenytoin) taken during pregnancy is a known risk factor in the development of cleft lip and cleft palate. Methyldopa is used during pregnancy for maintenance in women with chronic hypertension. Folic acid use is recommended during pregnancy to reduce the risk of cleft lip and palate. The use of an antidepressant (bupropion) has not been found to increase a woman's risk of developing a fetus with cleft lip or palate. Although bupropion can be used for smoking cessation, and maternal smoking can contribute to the development of cleft lip, taking bupropion does not increase a woman's risk of having a fetus affected by cleft lip or palate.

The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain?

1.Sternal rub 2.Nail bed pressure # 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle Rationale: Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse is caring for a 4-year-old child. When experiencing pain, the nurse anticipates which about the child? Select all that apply.

1.Views pain as a punishment # 2.Verbalizes the reason for the pain 3.Blames someone else for the pain # 4.Believes pain will disappear magically # 5.Fears losing control during the painful episode 6.Will be able to explain the sequence of events leading to the pain Rationale: Children from the ages of 2 to 7 years experience preoperational thought. Concepts of pain within this stage include viewing pain as punishment for wrongdoing, holding thinking in terms of pain disappearing magically, believing someone else is accountable for the pain, and relating to pain primarily as a physical and concrete experience. Options 2, 5, and 6 are not associated with concepts about pain for a child of this age.

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply.

2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus Rationale: Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem.

According to the American Cancer Society, fecal occult blood testing should be done annually after which age?

50 years old Rationale: Fecal occult blood testing for colorectal cancer should be done annually for both men and women after the age of 50 years. The other options are incorrect.

The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant?

90 to 150 mL Rationale: The stomach capacity is 10 to 20 mL for a newborn infant, 30 to 60 mL for a 1-week-old infant, 75 to 100 mL for a 2- to 3-week-old infant, and 90 to 150 mL for a 1-month-old.

A 12-month-old child with human immunodeficiency virus (HIV) infection is currently immunocompromised. The nurse determines that the immunization needs of this child include which action?

Delaying the administration of the varicella virus vaccine until the child is not immunocompromised Rationale: The immunocompromised child with HIV infection should not receive live vaccines. With both the varicella and the MMR vaccinations, live vaccines are given. Once the child's immune status improves, these vaccinations can then be given. The correct option is chosen because the varicella vaccination would be delayed until the child is not immunocompromised. The IPV is not a live virus, so it can be administered. Option 3 is incorrect because the MMR vaccine would not be administered at this time. Option 2 is incorrect because influenza vaccinations do not typically involve live viruses, so the child could receive these vaccinations.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

G = 2, T = 1, P = 0, A = 0, L = 1 Rationale: Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks' gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks' gestation; included in parity [number of births] if past 20 weeks' gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding?

Heavy Rationale: Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine (Nicorette) gum. When reviewing this treatment with the client, the nurse should provide which instruction to the client?

Hold the gum between the cheek and teeth periodically. Rationale: Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; food and drink should be avoided 15 minutes before or during use.

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes swollen lymph nodes and laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse provides instruction regarding care of the adolescent. Which statement made by the mother indicates an understanding of the care measures?

I will call the health care provider if my child has abdominal or left shoulder pain." Rationale: The mother needs to be instructed to notify the health care provider if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus.

When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?

Massage distended areas as the infant nurses. Rationale: Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. Soap should not be used on the nipples because of the risk of drying or cracking. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely.

A nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?

Mitral area Rationale: The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be counted for a full minute.

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia Rationale: In the test result for glycosylated hemoglobin A1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

A clinic nurse is explaining the changes in the integumentary system that occur during pregnancy to a client and should tell the client that which change may persist after she gives birth?

Striae gravidarum Rationale: Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. After birth they usually fade, although they never disappear completely. Options 1, 2, and 3 are incorrect. An epulis is a red, raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, browning hyperpigmentation of the skin over the cheeks, nose, and forehead and is especially noticed in dark-complexioned pregnant women. Chloasma usually fades after the birth. Telangiectasias, or vascular "spiders," are tiny star-shaped or branch-shaped, slightly raised, and pulsating end arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. The spiders usually disappear after delivery.

A pregnant client asks the nurse about the type of exercises that are allowable during pregnancy. Which exercise should the nurse instruct the client to engage in?

Swimming Rationale: Non-weight-bearing exercises are preferable to weight-bearing exercises. Non-weight-bearing exercise, such as swimming, is allowable during pregnancy. Competitive or high-risk sports, such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, aerobic exercising, and gymnastics, should be avoided. Other exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position should be avoided.

Weber Test

The Weber test is valuable assessment test when a client reports hearing that is better with one ear than the other. In this test, a vibrating tuning fork is placed on the client's head over the midlife of the client's skull. The client is then asked whether the tone sounds the same in both ears or better in one. The client should hear the tone by bone conduction through the skull, and it should sound equally loud in both ears.

A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which is documented in the client's record?

The cervix is completely dilated. Rationale: The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. The other options are not specific assessment findings of the second stage of labor.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff?

Two thirds of the distance between the antecubital fossa and the shoulder Rationale: The size of the blood pressure cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should cover two thirds of the distance between the antecubital fossa and the shoulder.

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates a need for further teaching?

"I cannot exercise because of the negative effects on insulin production." Rationale: Exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many women are taught to perform blood glucose monitoring. If the woman is not performing the blood glucose monitoring at home, then it will be performed at the clinic or health care provider's office. Signs of infection need to be reported to the health care provider.

A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose?

"The exercises will help strengthen the pelvic floor in preparation for delivery." Rationale: Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt exercises will help reduce backaches. Leg elevation will assist in preventing ankle edema. Instructing a client to drink 8 oz of fluids six times a day will help prevent urinary tract infections.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be most appropriate?

1."Has either of you ever had surgery?" 2."Do you plan to have any other children?"# 3."Do either of you have diabetes mellitus?" 4."Do either of you have problems with high blood pressure?" Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future.

A 6-month-old infant is admitted to the hospital. The nurse weighs the infant and notes that the infant weighs 14 pounds. Which statement by the mother indicates that further teaching is needed?

1."His weight for his age is just right." 2."I am so glad he is gaining the correct amount of weight for his age." 3."I will have to increase his milk intake because he is not gaining enough weight." Correct answer. 4."He weighed 7 pounds when he was born so he is at the correct weight for his age." Rationale: Newborns double their birth weight at 5 to 6 months of age and triple it by 1 year. Therefore, options 1, 2, and 4 are correct statements. Option 3 indicates the need for further teaching.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I plan on having bottled water available in the refrigerator so I can get additional fluids easily." Rationale: The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at the lowest risk for development of postpartum thromboembolic disorders?

1.A 39-year-old woman who reports that she smokes 2.A 26-year-old woman with a family history of thrombophlebitis. # 3.A 37-year-old woman in her fourth pregnancy who is overweight 4.A 22-year-old woman with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply.

1.A 47-year-old mother of a child with cystic fibrosis 2.A 54-year-old man scheduled for a routine diabetes check. 4.A 35-year-old registered nurse scheduled for an annual pelvic exam 5.An 87-year-old woman from a nursing home scheduled for a surgical follow-up Rationale: Influenza vaccinations are recommended yearly and developed according to predicted strain for clients at high risk. Influenza immunization is recommended for high-risk clients. Anyone in close contact with clients with a chronic respiratory or other chronic disorder should receive the vaccine. Adults with chronic metabolic disease such as diabetes mellitus are in the high-risk population. Residents of chronic care facilities are at risk for influenza. Health care workers are in the high-risk population. The influenza vaccine does not treat an active infection with the virus.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies is which category of decelerations?

1.Episodic, late decelerations that indicate uteroplacental insufficiency 2.Periodic, early decelerations and indicative of fetal head compression. # 3.Periodic, variable decelerations and an indication of cord compression 4.Episodic, early decelerations that may be a result of maternal hypotension. Rationale: An early deceleration is described as a visually apparent gradual decrease of the fetal heart rate with a gradual return to the FHR baseline. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described, so therefore eliminate option 3.

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?

1.Flashlight 2.Snellen chart 3.Reflex hammer 4.Ophthalmoscope Rationale: Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This card is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client. A flashlight is used to test the pupillary reaction. A reflex hammer is used to test reflexes. An ophthalmoscope is used to examine the retina.

A client experiencing "skipped heart beats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate (Toprol XL). The client returns to the health care provider's office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment?

1.Follow-up database # 2.Emergency database 3.Complete health database 4.Problem-centered database Rationale: A follow-up database is used in evaluating the status of an identified problem at regular and appropriate intervals. An emergency database is used for rapid collection of data, often compiled concurrently with lifesaving measures. A complete health database is the framework for a complete health history and full physical examination. The information thus obtained describes the current and past health state and forms a baseline against which all future changes can be measured. An episodic (problem-centered) database is used for a limited or short-term problem. It focuses mainly on one problem or one body system.

The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply.

1.Provide sufficient lighting. # 2.Set the room temperature at a comfortable level. # 3.Ensure that the distance between the nurse and client is no more than 3 feet. 4.Arrange seating so that the nurse sits behind the desk across from the client. 5.Make sure that the client will be seated comfortably at eye level with the nurse.# 6.Leave equipment needed for the physical exam on the desk so that they are readily available. Rationale: When preparing the physical environment for an interview, the nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. The nurse should set the room temperature at a comfortable level. The nurse should arrange seating so that both the nurse and the client are seated comfortably at eye level. The distance between the nurse and the client should be set by the nurse at 4 to 5 feet. If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen by the client as distant and aloof. The nurse avoids facing the client across a desk or table because this creates a barrier. Distracting objects and equipment should be removed from the interview area.

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.

1.Sunscreen should be applied every 8 hours. 2.Use sunscreen when participating in outdoor activities.# 3.Wear a hat, opaque clothing, and sunglasses when in the sun.# 4.Avoid sun exposure in the late afternoon and early evening hours. 5.Examine your body monthly for any lesions that may be suspicious.# Rationale: The client should be instructed to avoid sun exposure between the hours of 10 am and 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

The nurse is performing a neurological assessment on a client who had a brain attack (stroke). The nurse checks for proprioception by which assessment technique?

1.Tapping the Achilles tendon using the reflex hammer 2.Gently pricking the client's skin on the dorsum of the foot in two places 3.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument 4.Holding the sides of the client's great toe and, while moving it, asking what position it is in. Correct answer. Rationale: A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Option 1 describes gastrocnemius muscle contraction. Option 2 describes two-point discrimination. Testing the plantar reflex is described in option 3.

The nurse is observing a caregiver minimize misbehavior when a child is playing with an excessively noisy toy. The nurse recognizes that instruction is needed about the appropriate way to do this is needed if the caregiver takes which action?

1.Tells the child, "Put that toy down." 2.Instructs the child, "Don't touch that toy." # 3.Interacts with the child in a quiet, calm voice. 4.Offers the child a quiet toy in exchange for the noisy one. Rationale: Minimizing misbehavior includes teaching desirable behavior through example, such as using a quiet, calm voice rather than screaming. Requests for appropriate behavior should be phrased positively, such as, "Put that toy down," rather than, "Don't touch that toy." Alternatives should be offered to annoying actions, such as offering a quiet toy for one that is excessively noisy.

The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the heart rate is within normal range if which heart rate is noted on assessment?

130 beats/min Rationale: The normal heart rate for a newborn infant ranges from approximately 120 to 160 beats/min. Options 1 and 2 indicate bradycardia. Option 4 indicates tachycardia.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion?

2. History of syphilis Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.

The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted?

A heart rate of 140 beats/min Rationale: The normal heart rate in a newborn is 110 to 160 beats/min. The other options are incorrect.

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

A sedentary 65-year-old woman who smokes cigarettes Rationale: Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increases the risk.

A nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. What should the nurse determine that this sign indicates?

A softening of the cervix Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, causing Goodell's sign. Cervical softening is noted by the examiner during pelvic examination. Goodell's sign does not indicate the presence of fetal movement. The presence of hCG is noted in the maternal urine in a urine pregnancy test. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulation through the placenta.

A nurse is preparing to test cranial nerve V in a client. The nurse should obtain which item to test this nerve?

A wisp of cotton Rationale: A wisp of cotton would be used to assess the sensory function of cranial nerve V (the trigeminal nerve). Cranial nerve I (the olfactory nerve) is assessed by testing the sense of smell (using a non-noxious aromatic substance such as coffee beans) in a client who reports the loss of smell. A tuning fork would be used to assess cranial nerve VIII (the acoustic nerve). An ophthalmoscope would be used to assess the internal structures of the eye.

An infant is brought to the clinic for his third diphtheria-tetanus toxoid-acellular pertussis vaccination (DTaP). The mother reports that the infant developed a 99.4° F temperature after the last DTaP. Which action is most appropriate?

Administer the vaccination. Rationale: The vaccination should be given. Mild fever after the DTaP is not uncommon, and the vaccination would not be withheld for that reason. A vaccination is withheld for true contraindications such as a previous anaphylactic reaction or sensitivity to a product in the vaccination.

A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?

Allow the child to interact with others in his or her same age group. Rationale: Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the child from the peer group.

A nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA?

Anorexia Rationale: Early clinical manifestations of RA include complaints of fatigue, generalized weakness, anorexia, and weight loss

The postpartum unit nurse has provided information regarding performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that the sitz bath will promote which action

Assist in healing and provide comfort. Rationale: Warm, moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to reduce edema and numb the tissue. Promoting a bowel movement is best achieved by ambulation.

The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action?

Initiate a gentle upward tap on the cervix. Rationale: Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger.

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area?

Oral mucosa Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would best be noted in the sclerae of the eye. Cyanosis would be best noted in the palms of the hands and soles of the feet.

The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the eardrops correctly, the mother needs to take which action?

Pull down and back on the earlobe and direct the solution toward the wall of the canal. Rationale: The infant should be turned onto the side, with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the mother pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal.

The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). The nurse would gather which items to perform the test?

Safety pin, hot and cold water in test tubes, cotton wisp Rationale: The trigeminal nerve has motor and sensory divisions. The motor division innervates the muscles for chewing (mastication). The sensory division innervates the entire face, scalp, cornea, and nasal and oral cavities. The sensations of pain, temperature, and touch can be assessed using each of the respective items noted in the correct option. The corneal reflex (motor division) also can be tested using the cotton wisp. The supplies noted in the remaining options are used for testing cranial nerves VIII, II, and III respectively.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

Separate the client's jaw by pushing down on the chin. Rationale: The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Bringing a wisp of cotton in from the side of the eye and lightly touching the cornea will assess the corneal reflex. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.

A nurse has provided dietary instructions to a client with renal calculi who must learn about the foods that yield an alkaline residue in the urine. The nurse determines that the client has properly understood the information presented when the client chooses which selections from a diet menu?

Spinach salad, milk, and a banana Rationale: In some client situations, the health care provider may prescribe a diet that consists of foods that yield either an alkaline or an acid residue in the urine. In an alkaline residue diet, all fruits are allowed except cranberries, blueberries, prunes, and plums.

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include?

The hearing aid should not be worn if an ear infection is present." Rationale: The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use, and the client should keep extra batteries on hand at all times.

The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity?

The use of latex condoms Rationale: Mucosal exposure to latex can occur on contact with latex condoms. The nurse most appropriately would provide instructions to the client about the need to avoid the use of condoms unless they are latex free. No reason exists for the client to avoid outdoor activities or sunlight or to avoid parties; however, the client should be informed that certain forms of balloons are made of latex.

The nurse encourages a pregnant human immunodeficiency virus (HIV)-positive client to report any early signs of vaginal discharge or perineal tenderness to the health care provider immediately. The client asks the nurse about the importance of this action, and the nurse responds by telling the client which accurate statement?

This is necessary to assist in identifying potential infections that may need to be treated." Rationale: The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. All other options do represent possible outcomes of this nursing intervention, but they are not the priority of care when promoting maternal-fetal well-being.

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action?

Thoroughly dry the newborn. Rationale: An optimal thermal environment is essential to the effective care of a neonate. If a newborn is not thoroughly dried and placed in a warm environment immediately after delivery, cold stress may result. Infants respond to cold stress through an increased need for oxygen and depletion of glucose stores, resulting in an increased respiratory rate and possibly cyanosis. Although auscultating the heart rate is essential in the initial assessment of the newborn, palpating the heart rate via the umbilical cord can be done while drying the infant. Drying the infant should only take a few seconds and auscultating the heart rate can be done immediately afterward. The Apgar score is assessed at 1 and 5 minutes of life. Taking the temperature is not a priority immediately following delivery.

A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes the student perform this procedure. Which observation by the instructor indicates that the student is using correct technique for the procedure?

Tilting the client's head slightly away and holding the otoscope upside down before inserting the speculum. Rationale: In the otoscopic examination, the nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back, and the nurse visualizes the external canal while slowly inserting the speculum. A small speculum is used in pediatric clients. The nurse may not be able to adequately visualize the ear canal if a small speculum is used in the adult client.

A nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right breast, the nurse would tell the client to place a pillow in which location?

Under the right shoulder Rationale: The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the right breast is to be examined, the pillow would be placed under the right shoulder, and vice versa. Therefore options 1, 2, and 4 are incorrect.

The nurse who volunteers at a senior citizens' center is planning activities for the members who attend the center. Which activity would best promote health and maintenance for these senior citizens?

Walking three to five times a week for 30 minutes Rationale: Exercise and activity are essential for health promotion and maintenance in the older adult and to achieve an optimal level of functioning. Much of the physical deterioration of the older client is caused by disuse rather than by the aging process or disease. One of the best exercises for an older adult is walking, progressing to 30-minute sessions three to five times a week. Swimming and dancing also are beneficial.

The nurse is performing a voice test to assess the hearing of a client. Which describes the accurate procedure for performing this test?

Whisper a statement while the client blocks one ear. Rationale: In the voice test, the examiner stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it