NCLEX-PN Health Promotion and Maintenance

A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse should make which suggestion to the mother?

"Allow the bottle if it contains water."

A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that which is the safest exercise?

Swimming

The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching?

"I should use a dehumidifier, especially during the winter months."

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?

Beginning of toilet training

The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Individuals with spina bifida

The nurse is assisting in developing a plan of care for the client with immunodeficiency. The nurse should determine that which problem is a priority for the client?

Infection

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?

"At this age, the child is developing his or her own personality."

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

"Do you plan to have any other children?"

The nurse reinforces instructions to parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which should the nurse include in the instructions?

"Feed the infant in an upright position."

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?

"I do not feel any urges yet to empty my bladder."

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?

"I don't need birth control because I will be breastfeeding."

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 pm."

The client who received a kidney transplant is taking azathioprine, and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for further teaching?

"I need to discontinue the medication after 14 days of use."

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed?

"I will flush the eyes after instilling the ointment."

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory?

"Individuals move through all six stages in a sequential fashion."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement?

"Moving to a warmer climate should help."

The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?

"My left breast is sore, so I will offer only my right breast frequently for breastfeeding."

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the school children. Which statement, if made by a parent, indicates a need for further teaching regarding this communicable disease?

"The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."

The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of a plaster cast. Which statement should the nurse include in the instructions? Select all that apply.

"The foot should be kept elevated for the first 24 to 48 hours." "Reposition the infant every 2 to 4 hours until cast is thoroughly dried." "The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape."

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement?

"The moon follows me, and goes to bed when I go to bed".

The nurse has reinforced instructions to the client who has been prescribed cholestyramine. Which statement by the client indicates a need for further teaching?

"This medication should only be taken with water."

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

16 and 20 weeks' gestation

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?

18

The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise should be used as tools to keep the total cholesterol level under at least which level?

200 mg/dL

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?

26 cm

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to the figure.

3

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

A man who is an inspector for the U.S. Postal Service

The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this condition?

A sensorineural hearing loss that occurs with aging

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?

A softening of the cervix

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection?

Acquired immunity from disease

The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse determines the UAP understands the information provided if the UAP identifies which situation portrays ageism?

Advising older adults to forgo aggressive treatment

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents?

Allow the infant to signal a need.

The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply.

Alopecia Elevation in prostate specific antigen (PSA) levels

Which individual is least likely to be at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teachingwhen the client selects which foods as sources high in potassium? Select all that apply.

Bread and butter Carrots and peas Peppers and onions

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Cardiovascular disease

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?

Drink a half a cup of orange juice before soccer practice.

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?

Drink decaffeinated coffee and tea.

The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply.

Eggs Chicken

The nurse is reinforcing dietary instructions to the client prescribed cyclosporine. Which priorityfood item should the nurse instruct the client to avoid?

Grapefruit juice

The nurse is preparing to perform an abdominal examination. Which step should be taken first?

Inspection

The nurse prepares to assist in instructing a client about Lyme disease. Which should the nurse include in the instructions?

It is caused by a tick carried by deer.

The nurse is reinforcing instructions to a community group regarding the risks and causes of bladder cancer. The nurse determines that there is a need for further teaching if a member of the community group makes which statement regarding this type of cancer?

It most often occurs in women.

A child seen in the clinic is found to have rubeola (measles) and the mother asks the nurse how to care for the child. Which instruction should the nurse provide to the mother?

Keep the child in a room with dim lights.

The nurse is reinforcing instructions to a group of female clients about breast self-examination (BSE). When should the nurse instruct the pre-menopausal client to perform this examination?

One week after menstruation begins

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent?

Set limits on the child's behavior.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item?

Smoking history

The clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to the child. The nurse should administer this vaccine by which method?

Subcutaneously in the outer aspect of the upper arm

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

The nurse reinforces instructions to the client about breast self-examination (BSE). The nurse instructs the client to lie down and examine the left breast. Which is the correct area for placing a pillow when examining the left breast?

Under the left shoulder

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

Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. Examine your body monthly for any lesions that may be suspicious.

The client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition?

Vomiting following cancer chemotherapy

The nurse is providing an education class to healthy older adults. Which exercise will bestpromote health maintenance?

Walking three to five times a week for 30 minutes

The nurse reinforces medication instructions to the client who had a kidney transplant about therapy with cyclosporine. Which statement by the client should indicate a need for further teaching?

"I need to obtain a yearly influenza vaccine."

The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?

"I should turn the hearing aid off after removing it from my ear."

The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker

The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care?

Apply a moisturizing lotion to dry feet, but not between the toes.

The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items should the nurse instruct the client to avoid? Select all that apply.

Bacon Salami Processed oat cereals

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.

Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?

Begin with the eyes and face.

In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.

Change breast pads frequently. Avoid the use of soap on your nipples. Intermittently expose your nipples to the air.

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?

Check for signs of thrombophlebitis.

Mycophenolate mofetil is prescribed for the client as prophylaxis for organ rejection following an allogeneic renal transplant. Which instruction should the nurse most reinforce regarding administration of this medication?

Contact the primary health care provider (PHCP) if a sore throat occurs.

The home care nurse is prescribing dressing supplies for the client who has an allergy to latex. The nurse should ask the medical supply personnel to deliver which items?

Cotton pads and silk tape

The home care nurse is assigned to care for the client who returned home following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs to reinforce instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should do which action?

Cover the crutch pads with cloth.

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

DTaP, Hib, IPV, pneumococcal vaccine (PCV)

When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply.

Decline in visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record should the nurse identify as a risk factor for this diagnosis?

Diabetes mellitus

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

Document the findings and continue to monitor the fetal patterns.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee.

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

Eye medications may need to be administered for the rest of your life.

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor should the nurse take into account?

Fears of separation and mutilation are present.

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client?

G = 2, T = 1, P = 0, A = 0, L = 1

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include? Select all that apply.

Perform TSE after a shower or bath. Perform TSE on the same day each month. Perform TSE by rolling each testicle between the thumb and fingers.

The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. The nurse should determine that which client population is at risk for developing this type of allergy?

Hairdressers

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor?

High-calcium diet consumption

The nurse is reviewing the serum electrolyte laboratory results of a client and finds that the client has an elevated magnesium level. Which part of the client's history is likely associated with this problem?

History of chronic laxative use

The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likelytreating which condition?

Hyperlipidemia

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date?

July 27, 2020

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse should question the client about an allergy to which food items? Select all that apply.

Kiwi Bananas

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply.

Listening to lung sounds Obtaining the client's temperature Obtaining information about the client's respirations

The nurse is assisting with conducting a health-promotion program at a local school. The nurse determines that there is a need for further teaching if a student identifies which risk factors associated with cancer? Select all that apply.

Low-fat and high-fiber diets Maintaining a normal weight

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is caused by a tick carried by deer.

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down.

The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize?

Monitor blood glucose level frequently.

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.

Oranges Broccoli Grapefruit

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information?

Palms of the hands

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse should include which risk factor for colorectal cancer in the material?

Personal history of ulcerative colitis or gastrointestinal (GI) polyps

The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium?

Pork

A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client?

Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.

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

Preventing and recognizing hyperglycemia

The nurse is reinforcing instructions to a client about the types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? Select all that apply.

Prune juice Apple juice Cranberry juice

The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply.

Raisins Kiwifruit Bananas

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet?

Rice

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?

Tell the client that these are common and they may occur throughout the pregnancy.

The nurse is reinforcing instructions to a client on performing a testicular self-examination (TSE). Which instructions should the nurse provide to the client? Select all that apply.

The best time for the examination is after a shower. Set up a schedule of performing TSE on the same day each month.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?

The client is wearing knee-high hose.

The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding?

The finding is normal.

The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client?

The potential for decreased effectiveness of the birth control pills exists while taking phenytoin.

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction should the nurse include?

Take a blood glucose test before exercising.

A 6-month-old infant receives a diphtheria, tetanus, and pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which is the appropriate response by the nurse?

"Apply an ice pack to the injection site."

A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). Which response made by the nursing student is correct?

"BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB."

The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a need for further teaching?

"I'm glad I can still drink as much coffee as I want."

The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse should make which suggestion to the mother?

"Inform the child of bedtime a few minutes before it is time for bed."

The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statement?

"Resting in a sauna will be a relaxing form of activity."

The nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother what information? Select all that apply.

"The child should not be forced to sit on the potty for long periods." "The ability of the child to remove clothing is a sign of physical readiness." "Waiting until the child is 24 to 30 months old makes the task considerably easier." "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents."

The nurse is reinforcing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother?

"The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply.

"The preembryonic period is the first 2 weeks of fetal development following conception." "The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers."

Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching?

"The symptoms increase in severity after the rash appears."

The nurse is assisting the primary health care provider with performing a Rinne tuning fork test on a client. The nurse expects that the steps of the testing will be performed in which priorityorder? Arrange the actions in the order that they would be performed. All options must be used.

1. Tap tuning fork to activate. 2. Place base of tuning fork on the mastoid bone. 3. Have client indicate when the sound disappears. 4. Move the tuning fork close to the ear canal. 5. Ask the client if he or she hears the sound and to indicate when the sound disappears. 6. Document whether bone or air conduction is better.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement?

Two thirds the distance between the antecubital fossa and the shoulder

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign?

Violet bluish color of vaginal mucosa and cervix

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test?

Examines visual fields or peripheral vision

The nurse is reviewing the medical history of a client admitted to the hospital with a diagnosis of colorectal cancer. The nurse understands that which information documented in the medical history are risk factors of this type of cancer? Select all that apply.

Family history of colon cancer A history of inflammatory bowel disease Regular consumption of red or processed meats Regular consumption of a diet high in fats and carbohydrates

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position should the nurse place the client?

In a sitting position

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should be appropriate?

Instruct the client that these are common and may occur throughout the pregnancy.

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs?

Irregular, painless contractions

The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?

Maintaining body weight at or above minimum recommended levels

The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?

Place the client in a supine position and place a wedge under the right hip.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. According to the nurse, what is the purpose of progesterone?

Progesterone maintains the uterine lining for implantation.