NUR 414A Exam 2 Silvestri Questions

What is the average optimal blood pressure of an adolescent? 1. 85/54 mm Hg 2. 95/65 mm Hg 3. 105/65 mm Hg 4. 110/65 mm Hg

4. 110/65 mm Hg Rationale: The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure in an infant is 85/54 mm Hg. The average optimal pressure in a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 is 105/65 mm Hg.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal? 1.Presence of dark red lochia 2.Palpation of the uterus as a firm, contracted ball 3.The saturation of more than 1 peripad per hour 4.Palpation of the fundus at the level of the umbilicus

3. the saturation of more than 1 peripad per hour Rationale:Saturation of more than 1 peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Postpartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Subject

The nurse knows that which of the following are indicators of family coping? 1. confronting family members by attending group counseling 2. maintaining equilibrium between complimentary roles 3. using drugs and alcohol to cope with the loss of a loved one 4. emotional bonding between family members

1. confronting family problems by attending group counseling Rationale: Confronting family problems, involving family members in decisions, and using family-centered stress reduction techniques are all indicators of family coping. Option A is incorrect because using drugs and alcohol as a way to cope results in dysfunction and familial disorganization. Option C is incorrect; this is the definition of family cohesion. Option D is incorrect because maintaining equilibrium between complimentary roles is accomplished through family dynamics.

Exemplars of negative/dysfunctional family dynamics include (Select all that apply.) 1. sibling rivalry 2. codependency 3. traumatic injury of a family member 4. divorce/remarriage 5. marital infidelity

1. sibling rivalry 2. codependency 5. marital infidelity Rationale: Codependency, marital infidelity, and sibling rivalry are exemplars of negative/dysfunctional family dynamics. Divorce/remarriage and traumatic injury of a family member are exemplars of changes to family dynamics.

The embryonic period is critical because external and internal structures in the fetus are forming. All teratogens should be avoided from 1. 16 to 20 weeks 2. 8 to 12 weeks 3. 4 to 8 weeks 4. 12 to 16 weeks

3. 4 to 8 weeks Rationale: The embryonic period lasts from the beginning of the fourth week to the end of the eighth week. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. A woman should avoid exposure to all potential toxins during pregnancy, especially alcohol, tobacco, radiation, and infectious agents. At the end of this period, the embryo has human features. The span of gestation from 8 to 12 weeks, from 12 to 16 weeks, or from 16 to 20 weeks is not within the embryonic stage of fetal development, when teratogenicity is of greatest concern.

The nurse encounters a patient who asks, "What defines a family?" The best response to the question is: 1. a family can only be defined by blood relatives, such as ancestors 2. a family always consists of a mother, father and their children 3. a family is who they say they are 4. a family is the secondary unit of socialization

3. a family is who they say they are Rationale: A family is ultimately defined by who they say they are. Option A is incorrect because a family has been viewed traditionally as the primary unit of socialization. Option B is incorrect because although a family can include blood relatives, it can also include stepparents, adopted children, or two nonrelated adults without children. Option C is incorrect because, although this describes a traditional nuclear family, a family can also include same-sex families with or without children.

Which statement is true according to Piaget's theory of cognitive or moral development in the adolescent? Select all that apply. 1. The child is egocentric. 2. The child uses symbols. 3. The child develops abstract thinking. 4. The child is in the formal operations period. 5. The child is in the pre-operational period.

3. the child develops abstract thinking 4. the child is in the formal operations period Rationale: According to Piaget's theory of cognitive or moral development in an adolescent, a child is in formal operations period and develops abstract thinking. The child is egocentric and begins using symbols in the preschool developmental stage. In the toddler stage, the child is in the pre-operational period and starts to think about using symbols.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1.Chest pain 2.A rigid abdomen 3.A soft and boggy uterus 4.Complaints of severe abdominal pain

4. complaints of severe abdominal pain Rationale:Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Assessment Priority Concepts: Pain, Reproduction Strategy(ies): Strategic Words, Subject

What are the greatest risks for injury for an adolescent? Select all that apply. 1. Poisoning 2. Abduction 3. Home accidents 4. Substance abuse 5. Automobile accidents

4. substance abuse 5. automobile accidents Rationale: Substance abuse and automobile accidents pose the greatest risks of injury among adolescents. Poisoning and child abduction are more common among toddlers and preschoolers. Home accidents are common among toddlers as well.

The nurse should take which nursing actions when caring for a postpartum client who begins to hemorrhage? Select all that apply. 1.Assess for uterine atony: 2.Prepare to administer blood or blood products as prescribed. 3.Insert an indwelling urinary catheter to monitor kidney perfusion. 4.Administer 8 to 10 L/min of oxygen via non-rebreather face mask. 5.Administer uterotonic medications as prescribed to increase uterine tone.

ALL CORRECT Rationale:In the postpartum client, if bleeding is excessive and signs of shock are evident, the nurse immediately contacts the primary health care provider (PHCP) because this is a life-threatening situation. The nurse never leaves a client who is unstable or experiencing a life-threatening condition and would ask another nurse to contact the PHCP. The nurse should quickly attempt to determine the cause of the hemorrhage, and if the client is experiencing uterine atony, the nurse should massage the uterus gently to cause it to contract (do not push on an uncontracted uterus). The nurse positions the client to assist in perfusion of body organs; implements prescriptions, including oxygen administration; and monitors vital signs. Medications to contract the uterus, fluids to restore circulating blood volume, and blood replacement therapy may be prescribed in addition to other emergency medications. Surgical intervention may be required if the bleeding is caused by a laceration or retained placental fragments. The nurse then records the event, the interventions instituted, and the client's response to interventions. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

The client has undergone mastectomy. The nurse determines that the client is making the best adjustment to the loss of the breast if which behavior is observed? 1.Refusing to look at the wound 2.Reading the postoperative care booklet 3.Asking for pain medication when needed 4.Participating in the care of the surgical drain

Rationale:The client demonstrates the best adaptation by participating in her own care. This would include care of surgical drains that are in place for a short time after discharge. Refusing to look at the wound indicates no adaptation to the loss. Reading the postoperative care booklet is useful but is not the best of the options presented here. Asking for pain medication is an action-oriented option, but it does not relate to acceptance of the loss of the breast. Client Needs: Psychosocial Integrity Cognitive Ability: Evaluating Content Area: Adult Health: Oncology Health Problem: Adult Health: Cancer: Breast Integrated Process: Nursing Process/Evaluation Priority Concepts: Coping, Sexuality Strategy(ies): Strategic Words

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. after a shower or bath 2. while standing to void 3. after having a bowel movement 4. while lying in bed before arising

1. after a shower or bath Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Health Assessment/Physical Exam: Testicles Integrated Process: Teaching and Learning Priority Concepts: Client Education, Sexuality Strategy(ies): Strategic Words

The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply. 1.A blood test will confirm the diagnosis. 2.Syphilis signs and symptoms are divided into stages. 3.Syphilis can be spread through vaginal, anal, or oral sex. 4.Having syphilis once provides lifelong immunity from repeat infection. 5.Syphilis will always be present in a chronic state, as there is no cure for this illness.

1. a blood test will confirm the diagnosis 2. syphilis signs and symptoms are divided into stages 3. syphilis can be spread through vaginal, anal, or oral sex Rationale:Syphilis can be cured with the initiation of prompt treatment. A blood test can confirm this diagnosis. Syphilis is staged in relation to signs and symptoms and the length of the infection. Syphilis may be transmitted via vaginal, anal, or oral sex. An individual may be positive for syphilis more than once. Syphilis can be cured by early treatment. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Adult Health: Reproductive Health Problem: Adult Health: Reproductive: Inflammation/Infections Integrated Process: Teaching and Learning Priority Concepts: Client Education, Sexuality Strategy(ies): Subject

What instructions should a nurse provide to adolescent boys regarding the usual procedure to be followed and normal findings observed during testicular self-examination. Select all that apply. 1. A firm, smooth, egg-shaped organ can be palpated. 2. Each testicle is examined individually after relaxing the scrotal skin. 3. A hard mass that can be palpated on anterior or lateral aspect of testicle. 4. The thumb and fingers of both hands can be used to apply firm and gentle pressure. 5. A raised swelling that can be palpated on the superior aspect of the testicle is the epididymis.

1. a firm, smooth, egg-shaped organ can be palpated 2. each testicle is examined individually after relaxing the scrotal skin 4. the thumb and fingers of both hands can be used to apply firm and gentle pressure 5. a raised swelling that can be palpated on the superior aspect of the testicle is the epididymis Rationale: Testicular self-examination is usually performed after a warm bath when the scrotal skin is relaxed. A firm organ with smooth and egg shaped contours that can be palpated is the testicle. Each testicle is examined individually using thumb and fingers of both hands applying firm and gentle pressure. A raised swelling that can be palpated on the superior aspect of testicle is the epididymis. Testicular cancer can be suspected if a hard mass can be palpated on the anterior or lateral aspect of testicle.

A client diagnosed with severe preeclampsia is receiving magnesium sulfate by continuous intravenous infusion. Which assessment finding would indicate that the medication should be discontinued? 1.Absence of deep tendon reflexes 2.Respiratory rate of 16 breaths per minute 3.Urinary output of 45 mL during the past hour 4.Decrease in blood pressure from 180/100 mm Hg to 150/90 mm Hg

1. absence of deep tendon reflexes Rationale:Signs of magnesium toxicity include central nervous system depression. The respiratory system will fail with the absence of deep tendon reflexes if this condition is not corrected. The client should maintain a respiratory rate at or greater than 16 breaths per minute (or per agency protocol), maintain the presence of deep tendon reflexes, and maintain a urinary output greater than 30 mL/hour. A decrease in blood pressure is a positive finding because preeclampsia is accompanied by hypertension. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pharmacology: Maternity/Newborn: Magnesium Sulfate Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Evaluation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

A nursing instructor asks a nursing student to outline the factors that predispose adolescents to substance use. Which of these statements outlined by the student are correct? Select all that apply. 1. Adolescents believe that substance use makes them more mature. 2. Adolescents believe that substance use will improve appetite and sleep disturbances. 3. Adolescents believe that using mood-altering substances creates a sense of well-being. 4. Adolescents believe that substance use will help them achieve increased levels of performance. 5. Adolescents think that using substances will help them cope with worsening performance in school.

1. adolescents believe that substance use makes them more mature 3. adolescents believe that using mood-altering substances creates a sense of well-being 4. adolescents believe that substance use will help them achieve increased levels of performance Rationale: Some adolescents believe that substance abuse makes them more mature. Adolescents often believe that the use of mood-altering substances creates a sense of well-being. Adolescents also believe that substance use will result in an increased level of performance. Hence, all these statements outlined by the student are correct. Appetite and sleep disturbances and a decrease in school performance are warning signs of suicide among adolescents.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1.Age 54 years 2.Body mass index of 28 3.Previous difficulty with fertility 4.Administration of oxytocin for induction 5.Potassium level of 3.6 mEq/L (3.6 mmol/L)

1. age 54 years 2. body mass index of 28 3. previous difficulty with fertility Rationale:Risk factors that increase a woman's risk for dysfunctional labor include the following: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 54 years is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with fertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal, and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Dystocia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Data in the Question, Subject

A nurse is presenting a workshop on interpersonal violence prevention. Which is a common risk factor for most interpersonal violence incidents that should be addressed? 1. alcohol use 2. poor working conditions 3. poor self-esteem 4. hypertension medications

1. alcohol use Rationale: The use or misuse of alcohol is a risk factor in partner violence, child abuse, youth abuse, and elder abuse. Poor working conditions add to stress but would not be a risk factor that most abuse incidents have in common. Hypertension medications do not increase the risk of abusive episodes. Poor self-esteem is not a common risk factor for most abusive episodes.

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. 1.Assess blood pressure. 2.Check the urine for protein. 3.Assess deep tendon reflexes. 4.Discuss the need for hospitalization. 5.Teach the importance of keeping track of a daily weight.

1. assess blood pressure 2. check the urine for protein 3. assess deep tendon reflexes 5. teach the importance of keeping track of a daily weight Rationale:With mild cases of preeclampsia, the condition is monitored with self-care and bed rest at home. Before the need for hospitalization is discussed, the woman would need to be assessed for progression of the disease process. The nurse must assess blood pressure, weight, and the presence of protein in the urine because an increase in these areas would indicate a worsening condition. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): Subject

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? 1.Assess for signs and symptoms of labor. 2.Assess the client's temperature every 2 hours. 3.Schedule a daily ultrasound to assess fetal movement. 4.Schedule a nonstress test every 4 hours to assess fetal well-being.

1. assess for signs and symptoms of labor Rationale:As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): Steps of the Nursing Process, Strategic Words

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child? 1.Assess the child's physical status. 2.Ask the child how the injury occurred. 3.Report the case as suspected child abuse. 4.Observe the interactions between the child and his friends.

1. assess the child's physical status Rationale:The initial intervention is to assess the child's physical status. The child should be initially assessed for injury to the right arm and for bruises, burns, scars, and any other signs of abuse. The nurse would next report the case as suspected child abuse to the appropriate authorities. Option 2 may or may not be appropriate, depending on the situation because the child may be fearful of telling the truth about how the injury occurred. Option 4, although appropriate for some situations, is not appropriate as the initial intervention. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Health Assessment/Physical Exam: Assessment Techniques Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Implementation Priority Concepts: Interpersonal Violence, Pain Strategy(ies): Maslow's Hierarchy of Needs Theory, Strategic Words

The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client? 1.Avoid frequent douching. 2.Undergarments made of nylon are best. 3.Intrauterine devices are a good birth control method. 4.It is necessary to change sanitary pads only every 8 hours.

1. avoid frequent douching Rationale:The client who has been diagnosed with PID should avoid frequent douching because it decreases the natural flora that controls the growth of infectious organisms. The client should wear cotton undergarments, and clothes should not fit tightly. Intrauterine devices increase the client's susceptibility to infection. Sanitary pads should be changed at least every 4 hours. Tampons should not be used during the acute infection, and some primary health care providers may recommend avoiding them indefinitely. The client also should avoid strong soaps, sprays, powders, and similar products that will irritate the perineum. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Foundations of Care: Infection Control Health Problem: Adult Health: Renal and Urinary: Inflammation/Infections Integrated Process: Teaching and Learning Priority Concepts: Infection, Sexuality Strategy(ies): Subject

How do adolescents establish family identity during psychosocial development? Select all that apply. 1. By acting independently to make his or her own decisions 2. By evaluating his or her own health with a feeling of well-being 3. By fostering his or her own development within a balanced family structure 4. By building close peer relationships to achieve acceptance in the society 5. By achieving marked physical changes

1. by acting independently to make his or her own decisions 3. by fostering his or her own development with a balanced family structure Rationale: An adolescent establishes family identity by acting independently for taking important decisions about self. They also need to foster their development along with maintaining a balanced family structure. Health identity is associated with the evaluation of one's own health with a feeling of well-being. By building close peer relationships, an adolescent develops a sense of belonging, approval, and the opportunity to learn acceptable behavior. These actions establish an adolescent's group identity. The sound and healthy growth of the adolescent, with marked physical changes, helps to build an adolescent's sexual identity.

How do adolescents establish health identity during psychosocial development? Select all that apply. 1. By evaluating their own health with a feeling of well-being 2. By fostering their independence within a balanced family structure 3. By building close peer relationships to achieve acceptance in the society 4. By achieving marked physical changes with masculine and feminine behaviors 5. By having the ability to function normally in the absence of any disease or infirmity

1. by evaluating their own health with a feeling of well-being 5. by having the ability to function normally in the absence of any disease or infirmity Rationale: Adolescents establish health identity by evaluating their own health with a feeling of well-being. They also establish health identity by being able to function normally in the absence of any disease or infirmity. An individual establishes family identity by fostering their independence within balanced family structure. By building close peer relationships, an adolescent establishes a group identity. The sound and healthy growth of adolescents, characterized by marked physical changes, helps to build sexual identity.

A client calls the primary health care provider's office to schedule an appointment because she has missed 2 menstrual cycles and has always been very regular. The client receives an appointment for the next day. The nurse should expect which findings to be present at this prenatal visit if the client is pregnant? Select all that apply. 1.Chadwick's sign 2.Vertex presentation 3.Positive pregnancy test 4.Fetal heart rate audible by fetoscope 5.Fetal movement detectable by the mother

1. chadwick's sign 3. positive pregnancy test Rationale:Having missed 2 menstrual cycles with a normal history, the client is at approximately 8 weeks' gestation. Hormonal changes lead to vascular congestion in the cervix and vagina. The tissues have an appearance of looking "blue," and this change is identified by the term Chadwick's sign. In early pregnancy, human chorionic gonadotropin (hCG) is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for a positive pregnancy test. The pregnancy is not advanced significantly enough to be able to determine a presentation. Fetal heart rate is not audible by fetoscope until approximately 20 weeks. The earliest a mother experiences fetal movement is approximately 14 weeks. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Adult Health: Reproductive: Menstruation Problems/ Fertility/Infertility Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): Data in the Question

The nurse is caring for a patient who just lost her spouse. The patient is crying and her daughter is hugging and consoling her. The patient has indicated she is interested in grief counseling. When determining the patient's plan of care, the nurse is aware that the patient is experiencing which of the following: 1. changes to family dynamics 2. SIDS 3. ineffective coping strategies 4. dysfunctional family dynamics

1. changes to family dynamics Rationale: The death of a family member is considered to be a change to family dynamics. Defining attributes of family dynamics include involvement between family members, communication among family members, and interactions between family members that are fluid and changeable. Option B is incorrect. Although the patient is crying, this is not a dysfunctional action. The daughter is offering empathy and support, and the patient is using that support. Option C is incorrect. SIDS stands for "sudden infant death syndrome." Option D is incorrect. The patient is using effective coping strategies. Asking for information on grief counseling shows effective coping strategies.

The nurse is taking a health history of a 56-year-old male patient. He tells the nurse that he and his wife just got a divorce over 1 month ago, and he is now dating multiple women. He states that he is sexually active again after 2 months of abstinence during his divorce. The nurse knows that teaching should include: 1. condoms should always be used during sexual activity 2. longer periods of foreplay may be necessary before sexual intercourse now that the patient is in his fifties 3. the patient should not bother getting tested for sexually transmitted infections (STIs). STIs usually only occur in the adolescent age group 4. because the patient is in his fifties, impotence could be an issue. the patient should not use condoms

1. condoms should always be used during sexual activity Rationale: There is increasing concern regarding a decrease in condom use as men age, not because of a lack of sexual activity, but rather because of a lack of awareness that contracting an STI is possible, especially if sexual activity occurs with multiple partners. In this scenario, the nurse should educate the patient on condom use and possible STI testing as well. Longer periods of foreplay are often indicated for women, who have lower libidos than men. Although impotence can be a fear common to men older than 50 years of age, condom use should not be discouraged as contracting an STI can occur at any age. STIs can affect anyone in any age group. The nurse should encourage testing for STIs in a patient who has sexual contact with multiple partners.

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1.Hypertension 2.Low-grade fever 3.Generalized edema 4.Increased pulse rate

1. hypertension Rationale:A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

A nurse is assessing a menopausal female and discussing sexuality. Which statement is accurate regarding physiological effects of menopause on sexual health? 1. decreased lubrication is frequently cited as the cause for sexual problems 2. women who have undergone hysterectomy no longer desire to be sexually active 3. hot flashes are often bothersome and lead to decreased sexual interest 4. women taking hormone replacement therapy may not experience climax during sex

1. decreased lubrication is frequently cited as the cause for sexual problems Rationale: Women who perceive themselves as being attractive and having accessibility to a healthy partner often maintain a healthy sex life during their middle years. For many women, lack of lubrication is frequently cited as the cause for sexual problems as they reach middle age. A number of water-soluble lubricants are now readily available to provide relief for the pain that occurs during intercourse due to vaginal dryness. Hormone replacement therapy (HRT) is often used to treat the symptoms of menopause, most notably hot flashes and vaginal dryness. Hot flashes however are not known to be a main cause of decreased sexual interest. Taking HRT is not known to eliminate climactic experience during sex.

What health effects best describe a client who is the victim of abuse or negligence? Select all that apply. 1.Depression 2.Chronic fatigue 3.Involuntary shaking 4.Motivation to persevere 5.Interrupted sleeping patterns

1. depression 2. chronic fatigue 3. involuntary shaking 5. interrupted sleeping patterns Rationale:Clients who are victims of abuse or neglect are prone to certain health effects; these effects may be physical, such as bruises, broken bones, chronic fatigue, or involuntary shaking. The victim may also experience mental effects, such as nightmares, anxiety, post-traumatic stress disorder (PTSD), depression, interrupted sleep patterns, and low self-esteem. Motivation to persevere is not a direct effect and can be a positive characteristic. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Foundations of Care: Special Populations Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Safety Strategy(ies): Data in the Question, Strategic Words

The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? 1.Encourage the parents to touch their newborn. 2.Identify specific caregiving tasks that may be assumed by the parents. 3.Explain the equipment that is used and how it functions to assist the newborn. 4.Give the parents pamphlets that will help them understand their newborn's condition.

1. encourage the parents to touch their newborn Rationale:The best initial action to begin the attachment process and promote bonding is to encourage the parents to touch their newborn. The parents' initial need is to become acquainted with their newborn. Caregiving tasks may be frightening to the parents because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate later, as the newborn's condition becomes stable. Explaining equipment is important but is not specific to parent-newborn bonding activities. Providing pamphlets is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond. Client Needs: Psychosocial Integrity Cognitive Ability: Applying Content Area: Maternity: Newborn Health Problem: Newborn: Respiratory Problems Integrated Process: Caring Priority Concepts: Development, Family Dynamics Strategy(ies): Strategic Words, Subject

In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections? 1.Establish a therapeutic relationship. 2.Use specific closed-ended questions. 3.Omit these types of questions because they are highly personal. 4.Apologize for the embarrassment that these questions will cause the client.

1. establish a therapeutic relationship Rationale:The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned, purposeful communication that focuses on specific content. The remaining options are incorrect and would not lend themselves to eliciting accurate information from the client. Client Needs: Psychosocial Integrity Cognitive Ability: Applying Content Area: Maternity: Antepartum Integrated Process: Caring Priority Concepts: Infection, Sexuality Strategy(ies): Strategic Words, Subject, Therapeutic Communication Techniques

Despite the importance of sexual health to overall well-being, many nurses and patients are uncomfortable discussing issues related to sexuality. It is for this reason that the nurse must include questions regarding a sexual health history as part of a comprehensive health assessment. A 15-year-old female patient has come to the office for her annual physical and first pelvic examination. In this situation, which nursing action is most important? 1. excuse the parent 2. ensure the patient that all information will be kept confidential 3. screen for possible abuse 4. encourage the patient to ask questions about sexuality

1. excuse the parent Rationale: Although all of these actions are important, in this situation the parent should be excused in order to allow the teen to discuss her sexual concerns without fear of repercussions. Adolescents may be concerned about their altered appearance and impulse control. This is the ideal time to encourage the patient to ask questions and reassure her that she does not appear ignorant. All patients should be screened for possible abuse, and this is the most appropriate time to do so. If the parent remains present, the patient may be reluctant to answer a question honestly about any history of childhood sexual abuse. The nurse must pose all questions to the patient in a nonjudgmental manner and ensure her that all answers will be kept strictly confidential.

Which factors should the nurse consider when administering medications to adolescents? Select all that apply. 1. Explanation of the medication administration procedure by the nurse to the client 2. Interactive communication regarding the procedure of medication administration 3. Implementation of comfort measures like holding 4. Acceptance of aggressive behavior with certain limitations 5. Encouragement of self-expression, individuality, and self-care

1. explanation of the medication administration procedure by the nurse to the client 2. interactive communication regarding the procedure of medication administration 5. encouragement of self-expression, individuality and self-care Rationale: During administration of medication to the children of all age groups, the nurse should consider certain points. For adolescents, the nurse should provide a description regarding the procedure being conducted. The adolescent must be allowed to express fears and experiences regarding the administration, and self-expression, individuality, and self-care should be allowed and encouraged. Implementing comfort measures like holding are more appropriate for a younger age group, and accepting aggressive behavior with certain limitations is appropriate only for toddlers.

The nurse is counseling the parents of an adolescent child on the benefits of social development in the child's maturation process. Which statement by the nurse needs correction to convey an appropriate message to the parents? 1. Feelings of immortality in the child are undesirable and should be condemned. 2. The family should encourage the child to make relationships outside the family. 3. Feelings of intense sociability and equally intense loneliness are normal in the child. 4. The family should encourage the child to develop an identity independent of parental authority.

1. feelings of immortality in the child are undesirable and should be condemned Rationale: Social development is a critical aspect of a child's maturation process. The feelings of immortality and release from the results of risky behavior are common in adolescent children. Although such feelings can be dangerous, they function as important developmental tools. These feelings help the child gain courage to build a separate self-identity by freeing himself or herself from family domination. Therefore the nurse should explain the significance of these feelings even though they seem negative. The nurse should instruct the parents to encourage the child to form social relationships outside the family. This helps in emancipating the child. The nurse should explain to the parents that adolescence is a transition period during which a child experiences various emotions ranging from intense sociability to intense loneliness. The parents should support and encourage the child to develop an independent identity apart from the family authority to achieve full maturity.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1.Flushing 2.Hypertension 3.Increased urine output 4.Depressed respirations 5.Extreme muscle weakness 6.Hyperactive deep tendon reflexes

1. flushing 4. depressed respirations 5. extreme muscle weakness Rationale:Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pharmacology: Maternity/Newborn: Tocolytics Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Perfusion, Reproduction Strategy(ies): Subject

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1.Forceps delivery 2.Schultz presentation 3.Hypotonic contractions 4.Weak bearing-down efforts

1. forceps delivery Rationale:Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

In order to fully understand the concept of sexuality, it is necessary to become familiar with the terms used when discussing this topic. Which term best describes how one views oneself as masculine or feminine? 1. gender identity 2. sexual orientation 3. sexual behavior 4. sexual identity

1. gender identity Rationale: Gender identity is socially derived from experiences with family, friends, and society. Sexual identity is defined as whether one is male or female based on biological sexual characteristics. Sexual orientation is how one views oneself in terms of being emotionally, romantically, or sexually attracted to an individual of a particular gender. Sexual behavior is how one responds to sexual impulses and desires.

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. 1.Giving tepid sponge baths 2.Applying a hypothermia blanket 3.Covering the client with blankets 4.Administering acetaminophen per protocol 5.Placing ice packs over the client's abdomen and in the axilla and groin

1. giving tepid sponge baths 2. applying a hypothermia blanket 4. administering acetaminophen per protocol Rationale:Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Neurological Health Problem: Adult Health: Neurological: Thermoregulation Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Thermoregulation Strategy(ies): Subject

The nurse notes that the peak height velocity (PHV) for an 11-year-old female has occurred since the last health maintenance visit. Which assessment question should the nurse ask the adolescent based on this data? 1. "Have you begun to menstruate?" 2. "How tall do you think you will get?" 3. "What do you typically eat in a normal day?" 4. "Are you taller than most of the other girls in your class?"

1. have you begun to menstruate Rationale: An accelerated rate of linear growth is referred to as PHV. When this occurs for a school-age or adolescent female client, it is a predictor for menarche; therefore, asking the client if she has begun to menstruate is an appropriate assessment question. Typically, menarche begins 6 to 12 months after PHV. The other questions are not inappropriate, but they are not assessment questions that should be asked based on the current client data.

Which are general growth parameters for an adolescent client that the nurse will monitor during a growth and development assessment during a health maintenance visit? Select all that apply. 1. Height 2. Weight 3. Body mass 4. Blood pressure 5. Head circumference

1. height 2. weight 3. body mass Rationale: Growth parameters that the nurse includes in the growth and developmental assessment for an adolescent client includes height, weight, and body mass. Blood pressure is a vital sign, not a growth parameter. Head circumference is assessed until 36 months of age; therefore, this is not an appropriate growth parameter for the nurse to include in the growth and developmental assessment.

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing? 1.Hypotonic 2.Precipitate 3.Hypertonic 4.Preterm labor

1. hypotonic Rationale:Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Intrapartum Health Problem: Maternity: Dystocia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): Subject

According to Erikson's theory, which of these actions can predispose an adolescent to being in a state of confusion? 1. If an adolescent fails to establish a sense of identity 2. If an adolescent has a feeling of isolation and rejection 3. If an adolescent's parents fail to establish a sense of trust in him or her 4. If an adolescent's parents try to control him or her and limit his or her choices

1. if an adolescent fails to establish a sense of identity Rationale: Acquiring a sense of identity is essential for making adult decisions. If an adolescent fails to develop a sense of identity, they may end up in a state of confusion. If a young adult is not able to establish a companionship, isolation results due to rejection and disappointment. If the parents fail to establish a sense of trust with an infant, the child may develop feelings of mistrust. Controlling a child and limiting his or her choices may lead to a child developing a sense of shame and doubt.

A client has been prescribed pindolol for hypertension. The nurse provides anticipatory guidance, knowing that which common side effect of this medication may decrease client compliance? 1.Impotence 2.Mood swings 3.Increased appetite 4.Difficulty swallowing

1. impotence Rationale:A common side effect of beta-adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and difficulty swallowing are not side effects of this medication. Client Needs: Psychosocial Integrity Cognitive Ability: Applying Content Area: Pharmacology: Cardiovascular: Beta Blockers Health Problem: Adult Health: Cardiovascular: Hypertension Integrated Process: Teaching and Learning Priority Concepts: Adherence, Sexuality Strategy(ies): Subject

Which of these features are exhibited by an adolescent? Select all that apply. 1. Invulnerability 2. Personal fable 3. Temper tantrums 4. Attempts to control situations 5. Eagerness for formal education

1. invulnerability 2. personal fable Rationale: Adolescents believe they are are invulnerable, which frequently leads to risk-taking behaviors, especially in early adolescence. They show personal fable as they think their thoughts and feelings are unique. When the parents try to control the behavior of a toddler, it often leads to temper tantrums and negative behavior. Toddlers get to know their abilities to control situations and seem pleased with it. Preschoolers refine the mastery of their bodies and eagerly await the beginning of formal education.

A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic? 1.Is painless and indurated 2.Has a cauliflowerlike appearance 3.Is erythematous and papular in appearance 4.Appears as 1 or more vesicles that then rupture

1. is painless and indurated Rationale:The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Genital warts are characterized by cauliflowerlike growths or growths that are soft and fleshy. Scabies is characterized by erythematous, papular eruptions. Genital herpes is accompanied by the presence of 1 or more vesicles that then rupture and heal. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Foundations of Care: Infection Control Health Problem: Adult Health: Reproductive: Inflammation/Infections Integrated Process: Nursing Process/Assessment Priority Concepts: Infection, Sexuality Strategy(ies): Subject

A nursing instructor asks a nursing student to explain the teaching methods to be used for adolescents. Which statement by the student indicates a need for further teaching? Select all that apply. 1. Keep teaching sessions short 2. Use teaching as a collaborative activity 3. Use problem-solving to help adolescents make choices 4. Encourage them to learn together, using pictures and short stories 5. Help adolescents learn about feelings and the need for self-expression

1. keep teaching sessions short 4. encourage them to learn together, using pictures and short stories Rationale: Teaching sessions should be kept shorter for an older adult, not an adolescent. Preschoolers, not adolescents, are encouraged to learn together through the use of pictures and short stories. This helps make learning interesting for them. Hence, the nursing student's statements that teaching sessions should be kept shorter for the adolescent client and that adolescents should be encouraged to learn together through the use of pictures and short stories indicates a need for further teaching. The teaching should be such that it helps the adolescent understand his or her feelings and the need for self-expression. Teaching should be used as a collaborative activity in adolescents. A problem-solving approach can also be adopted to help adolescents make choices.

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. 5.Allow out-of-bed activity as tolerated.

1. keep the room semi-dark 2. initiate seizure precautions 3. pad the side rails of the bed 4. avoid environmental stimulation Rationale:Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure. Client Needs: Physiological Integrity Cognitive Ability: Creating Content Area: Maternity: Intrapartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Planning Priority Concepts: Perfusion, Safety Strategy(ies): Subject

The nurse is caring for a 14-year-old girl who is hospitalized and has been placed in traction using Crutchfield tongs. The child is having difficulty adjusting to the prolonged hospital confinement. Which nursing action would be appropriate to meet the child's needs? 1.Let the child wear her own clothing when friends visit. 2.Allow the child to have her hair dyed if the parent agrees. 3.Allow the child to play loud music in the hospital room. 4.Allow the child to keep the shades closed and the room darkened at all times.

1. let the child wear her own clothing when friends visit Rationale:Adolescents need to identify with their peers and have a strong need to belong to a group. They prefer to dress like the group and wear similar hairstyles, which are different from their parents'. The child should be allowed to wear her own clothes to feel a sense of belonging to the group. Because Crutchfield tongs require the use of skeletal pins, hair dye is not appropriate. Loud music may disturb others in the hospital. The child's request for a darkened room may indicate a problem with depression that may need further evaluation and intervention. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Developmental Stages: Adolescent Integrated Process: Nursing Process/Implementation Priority Concepts: Development, Health Promotion Strategy(ies): Subject

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1.Monitor for fetal movement. 2.Monitor the maternal blood glucose. 3.Instruct the client to maintain complete bed rest. 4.Instruct the client to restrict dietary sodium and any food items that contain sodium.

1. monitor for fetal movement Rationale:A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

A nurse communicates with a mother about the cognitive changes that her child will exhibit after becoming an adolescent. Which statements made by the mother indicate adequate learning? Select all that apply. 1. "My child will think in terms of the future." 2. "My child will be able to deal with hypothetical problems." 3. "My child will consider a limited variety of causes and solutions." 4. "My child will be able to imagine multiple outcomes of a situation." 5. "My child will be unable to understand the influence of an individual's ideas on others."

1. my child will think in terms of the future 2. my child will be able to deal with hypothetical problems 4. my child will be able to imagine multiple outcomes of a situation Rationale: Adolescents think in terms of the future, begin to deal with hypothetical problems, and can think of different outcomes of a situation. An adolescent considers an infinite variety of causes and solutions. An adolescent is also able to understand how an individual's ideas or actions influence others.

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1."My vision for the past 2 days has been really fuzzy." 2."The swelling in my hands and ankles has gone down." 3."I had heartburn yesterday after I ate some spicy foods." 4."I had a headache yesterday, but I took some acetaminophen and it went away."

1. my vision for the past 2 days has been really fuzzy Rationale:Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

You are working with a college student who is planning to become sexually active. She is requesting a reliable method of birth control that could be easily discontinued if necessary. Which option should be given the strongest recommendation? 1. oral contraceptive pills 2. intrauterine device (IUD) 3. coitus interruptus 4. natural family planning

1. oral contraceptive pills Rationale: Oral contraceptive pills prevent ovulation, are easy to stop, and are 99% effective in pregnancy prevention. Intrauterine devices, coitus interruptus, and natural family planning will not prevent ovulation; they should not be recommended for this college student who desires a reliable method of birth control that can be easily discontinued.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.Proteinuria 2.Hypertension 3.Low-grade fever 4.Generalized edema 5.Increased pulse rate 6.Increased respiratory rate

1. proteinuria 2. hypertension Rationale:The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply. 1."Some forms of HPV can lead to cervical cancer." 2."You cannot get HPV if you have had only 1 sex partner." 3."There are no vaccinations available to protect against HPV." 4."HPV is most commonly spread during vaginal or anal sexual contact." 5."In some types, HPV will go away on its own and does not cause health issues."

1. some forms of HPV can lead to cervical cancer 4. HPV is most commonly spread during vaginal or anal sexual contact 5. in some types, HPV will go away on its own and does not cause health issues Rationale:HPV has now become the most common sexually transmitted infection. Some types of HPV have been found to have a strong link to cervical cancer, while other types of HPV may resolve without any intervention. HPV may be contracted with any sexual partner. There is a vaccine for the known strains that may lead to cervical cancer, which can be administered to females from ages 9 to 26 years. HPV is spread through vaginal or anal sexual contact. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Adult Health: Reproductive Health Problem: Adult Health: Reproductive: Inflammation/Infections Integrated Process: Teaching and Learning Priority Concepts: Client Education, Sexuality Strategy(ies): Subject

The nurse is teaching a parent group about the reason to adhere to the immunization schedule. What is a complication of mumps that is important for adolescents to avoid? 1. Sterility 2. Hypopituitarism 3. Decrease in libido 4. Decrease in androgens

1. sterility Rationale: Mumps can cause orchitis (inflammation of the testes) in males and oophoritis (inflammation of the ovaries) in females. Although rare, both conditions can render the postpubescent child sterile. Hypopituitarism, diminished libido, and decreased levels of androgens are not associated with mumps.

What are the greatest risks for injury among adolescents? Select all that apply. 1. Suicide 2. Poisoning 3. Child abduction 4. Home accidents 5. Substance abuse 6. Automobile accidents

1. suicide 5. substance abuse 6. automobile accidents Rationale: Adolescents are at greater risk of suicide, substance abuse, and automobile accidents. Preschoolers are at a greater risk of poisoning and abduction. Children younger than 5 years are at greatest risk for home accidents that result in severe injury and death.

A nurse is teaching a group of parents about the developmental needs of adolescents. Which information is the nurse most likely to provide? Select all that apply. 1. The adolescent has an increased need for calories. 2. The adolescent's daily requirement of protein decreases. 3. The adolescent needs to consume iron in the diet on a daily basis. 4. The adolescent will show an increased inclination toward healthy food. 5. The adolescent's need for nutrition is better guided by physiologic age than chronologic age.

1. the adolescent has an increased need for calories 2. the adolescent needs to consume iron in the diet on a daily basis 5. the adolescent's need for nutrition is better guided by physiologic age than chronologic age Rationale: The nurse will tell parents that during adolescence, energy needs increase to meet the greater metabolic demands of growth. Adolescent girls need a consistent source of iron to replace menstrual losses. Boys also need adequate iron for muscle development. The nurse should tell parents that physiologic age is a better guide to nutritional needs than chronologic age is. The daily requirement for protein also increases in adolescents. Fast food, particularly value-size or super-size meals, are popular among teens. These foods contain extra salt, fat, and kilocalories and contribute to nutrient deficiency and obesity.

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks' gestation because of which factor? 1.The appearance of the fetal external genitalia 2.The beginning of differentiation in the fetal groin 3.The fetal testes are descended into the scrotal sac 4.The internal differences in males and females become apparent

1. the appearance of the fetal external genitalia Rationale:Between weeks 16 and 20, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes begin to descend into the scrotal sac at the end of the 38th week. Internal differences in the male and female occur at the end of the seventh week. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Maternity: Antepartum Integrated Process: Teaching and Learning Priority Concepts: Development, Sexuality Strategy(ies): Subject

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1.The client has a history of intravenous drug use. 2.The client has a significant other who is heterosexual. 3.The client has a history of sexually transmitted infections. 4.The client has had one sexual partner for the past 10 years. 5.The client has a previous history of gestational diabetes mellitus.

1. the client has a history of IV drug use 3. the client has a history of sexually transmitted infections Rationale:HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV. Client Needs: Safe and Effective Care Environment Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Infections/Inflammation Integrated Process: Nursing Process/Assessment Priority Concepts: Infection, Sexuality Strategy(ies): Subject

A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 37.2º C (99º F). The nurse plans care based on which interpretation? 1.The woman requires further evaluation for preterm labor. 2.The woman is suffering from an intestinal bacterial infection. 3.The woman is exhibiting signs and symptoms of gestational hypertension. 4.The woman needs instruction on pelvic tilts to decrease her lower back pain.

1. the woman requires further evaluation for preterm labor Rationale:Classic signs and symptoms of preterm labor include lower abdominal cramping, possibly accompanied by diarrhea; dull and intermittent low back pain; painful menstrual-like cramps; suprapubic pain or pressure; pelvic pressure or heaviness; urinary frequency; change in character and amount of vaginal discharge; and rupture of amniotic membranes. Early recognition of preterm labor is essential, so interventions such as tocolytic therapy and administration of antenatal glucocorticoids can be initiated; therefore, further evaluation of the cervix, membrane status, uterine activity, and fetal heart rate is necessary to determine if the client is in preterm labor (the correct option). The client's temperature is only slightly elevated, and her diarrhea presents in addition to the signs and symptoms of preterm labor, so option 2 can be eliminated. The client is not exhibiting signs of gestational hypertension, so therefore eliminate option 3. Because the client has additional complaints that may possibly relate to preterm labor, instruction on pelvic tilts to decrease back pain is irrelevant at this time, so therefore eliminate option 4. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Maternity: Antepartum Health Problem: Maternity: Preterm Labor Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): Subject

The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted? 1.The client looks at the surgical site. 2.The client performs the prescribed arm exercises. 3.The client takes the pain medication as prescribed. 4.The client has read all of the postoperative materials provided by the hospital nurse.

1. the client looks at the surgical site Rationale: Of the options provided, the client behavior in the correct option demonstrates the greatest adaptation or adjustment (looking at the surgical site). This indicates that the client has acknowledged and is beginning to cope with the loss of the breast. Reading postoperative care booklets and performing prescribed exercises indicate an interest in self-care and are positive signs indicating adjustment. Taking pain medication is not related to adjustment to the loss of the breast. Client Needs: Psychosocial Integrity Cognitive Ability: Evaluating Content Area: Adult Health: Oncology Health Problem: Adult Health: Cancer: Breast Integrated Process: Caring Priority Concepts: Coping, Sexuality Strategy(ies): Subject

The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? 1.The client's fear 2.The client's fatigue 3.The client's inability to control the situation 4.The client's inability to cope with the situation

1. the client's fear Rationale:The mother is anxious and frightened, and the most appropriate problem to address for the client at this time is fear. There are no data in the question to support a client problem with fatigue, inability to control the situation, or inability to cope with the situation. These problems may be considered for this client at some point during the hospitalization experience. Client Needs: Psychosocial Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Prolapsed Umbilical Cord Integrated Process: Nursing Process/Analysis Priority Concepts: Anxiety, Perfusion Strategy(ies): Strategic Words

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1.The client's fingers and toes are warm to touch. 2.The client's body temperature is 98º F (36.7º C). 3.The client remains in a fetal position when in bed. 4.The client complains of coolness in the hands and feet only.

1. the clients fingers and toes are warm to touch Rationale:Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are warm; body is relaxed and not curled; body temperature is greater than 97º F (36.1º C); the client is not shivering; and the client has no complaints of feeling cold. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Adult Health: Neurological Health Problem: Adult Health: Neurological: Thermoregulation Integrated Process: Nursing Process/Evaluation Priority Concepts: Clinical Judgment, Thermoregulation Strategy(ies): Closed-ended Word, Subject

What should a nurse do while communicating with a group of adolescents? Select all that apply. 1. The nurse should ask adolescents open-ended questions. 2. The nurse should avoid involving other individuals and resources. 3. The nurse should avoid discussing sensitive issues such as sex and drugs. 4. The nurse should be aware of clues about an adolescent's emotional state. 5. The nurse should avoid looking for the meaning behind an adolescent's words or actions.

1. the nurse should ask adolescents open-ended questions 4. the nurse should be aware of clues about an adolescent's emotional state Rationale: The nurse should ask open-ended questions while communicating with adolescents. The nurse should be alert to clues to adolescent's emotional state. The nurse may involve other individuals and resources whenever necessary. In addition, the nurse should discuss sensitive issues such as sex and drug topics. The nurse should search for the reasons or meanings behind an adolescent's words and actions.

A nurse is working in a school health promotion program for adolescents. Which of these actions should be included in the assessment process? Select all that apply. 1. The nurse should conduct a school violence assessment. 2. The nurse should assess the sleep pattern of the students. 3. The nurse should try identifying individuals at risk for substance abuse. 4. The nurse should identify the need for fluoride supplements to prevent dental caries. 5. The nurse should enquire about the presence of guns in the home to reduce the incidence of homicide.

1. the nurse should conduct a school violence assessment 3. the nurse should try identifying individuals at risk for substance abuse 5. the nurse should enquire about the presence of guns in the home to reduce the incidence of homicide Rationale: School violence is a serious problem among adolescents. Hence, in a school educational health promotional program for adolescents, the nurse should conduct a school violence assessment. The adolescent population is at increased risk for drug abuse, so the nurse should try to identify individuals who are engaging in substance abuse and counsel them. The presence of gun at home can increase the risk of homicide. Therefore, the nurse should also counsel parents to avoid keeping guns at home. Assessment of the sleep pattern is performed in infants because the sleep pattern fluctuates in children of this age. In preschoolers and school-age children, the need for fluoride supplements should be assessed to help prevent dental caries.

What should be included in the assessment of a school health promotional program for adolescents? Select all that apply. 1. The nurse should perform a school violence assessment. 2. The nurse should assess the sleep pattern of the students. 3. The nurse should identify individuals at risk for drug abuse. 4. The nurse should explain the need for fluoride supplements to prevent dental caries. 5. The nurse should teach the students about gun safety.

1. the nurse should perform a school violence assessment 3. the nurse should identify individuals at risk for drug abuse 5. the nurse should teach the students about gun safety Rationale: During a school educational health promotional program for adolescents, the nurse should perform a school violence assessment. The nurse should try to identify individuals with substance abuse problems and counsel them. The presence of a gun at home may predispose adolescents to a greater incidence of homicide. Therefore, the nurse should teach about gun safety. The assessment of sleep patterns is done in infants because they have fluctuating sleep patterns. Fluoride supplements for the prevention of dental caries is an important infant issue.

A nurse is teaching preadolescents about puberty. What should the nurse tell them about the primary sex characteristics? 1. They are related to reproduction. 2. They develop at the same rate in most adolescents. 3. Each sex is identified by the primary sex characteristics. 4. Primary sex characteristics are apparent before secondary sex characteristics.

1. they are related to reproduction Rationale: Primary sex characteristics are those that are related directly to reproduction—the release of an ovum from the ovaries in a female and the development of viable sperm in a male. The rate of pubertal development varies from adolescent to adolescent. Secondary sex characteristics are those related to maleness (e.g., pubic, axillary, and facial hair; deepening of the voice; increased muscularity) and femaleness (e.g., pubic and axillary hair, breast development). Primary sex characteristics are not apparent before secondary sex characteristics.

Which of these measures should the nurse adopt while performing the health assessment of an adolescent? Select all that apply. 1. Treating adolescents as adults 2. Addressing adolescents as "Mr." or "Ms." 3. Maintaining an adolescent's right of confidentiality 4. Performing the examination in a nonthreatening area 5. Gathering all the history of an adolescent from his or her parents or guardians

1. treating adolescents as adults 3. maintaining an adolescents right of confidentiality 4. performing the examination in a nonthreatening area Rationale: While performing a health assessment of adolescents, the nurse should treat adolescents as adults and maintain the adolescents' rights to confidentiality. The nurse should also conduct the examination in a nonthreatening area. While performing the assessment of an adolescent, a nurse should call him or her by his or her first name. The nurse should gather all the history of infants and small children from their parents or guardians.

Although sexual activity is considered a normative process, some individuals place themselves at increased risk for negative consequences related to this process. Which nonsexual behavior is likely to increase risk-taking activities? 1. using alcohol, marijuana, or illicit substances 2. having multiple sexual partner 3. having gay, lesbian, or bisexual partners 4. refraining from safe-sex practices such as condom use

1. using alcohol, marijuana, or illicit substances Rationale: The influence of nonsexual high-risk behavior such as the use of alcohol, marijuana, and illicit substances increases sexual risk-taking behavior. The abuse of alcohol or drugs results in impaired judgment and less thoughtfulness related to the sexual act, particularly when substances are ingested close to the time of sexual activity. More varied sexual experiences and intercourse with multiple partners are significant individual sexual risk-taking behaviors. Gay, lesbian, and bisexual youth, men who have sex with men, and women who primarily have sex with women have been found to engage in more high-risk sexual practices. Youth in particular are less likely to engage in safer sex practices such as condom use. This is a sexual behavior that significantly increases the risk for contracting sexually transmitted infections, including human immunodeficiency virus (HIV) infection, and for unintended pregnancy.

What teaching methods should be adopted for an adolescent? Select all that apply. 1. Using teaching as a collaborative activity 2. Encouraging questions and offering explanations 3. Teaching psychomotor skills needed to maintain health 4. Using role play, imitation, and play to make learning fun 5. Allowing adolescents to make decisions about health and health promotion

1. using teaching as a collaborative activity 5. allowing adolescents to make decisions about health and health promotion Rationale: Teaching should be framed as a collaborative activity in adolescents. An adolescent should be allowed to make decisions about health and health promotion. Preschoolers should be encouraged to ask questions, and answers should be provided through simple explanations and demonstrations. School-age children should be taught about the psychomotor skills needed to maintain health. The nurse should instruct mothers to include role play, imitation, and play to make learning fun for preschoolers. Independent learning should be encouraged in young and middle-aged adults.

When presenting a workshop on adolescent suicide, a community health nurse identifies which risk factors? Select all that apply. 1. Victim of family violence 2. Limited or strained family finances 3. Member of a single-parent household 4. Dependence on alcohol, drugs, or both 5. Uncertainty related to sexual orientation 6. Repeated demonstration of poor impulse control

1. victim of family violence 4. dependence on alcohol, drugs, or both 5. uncertainty related to sexual orientation 6. repeated demonstration of poor impulse control Rationale: Being a victim of family violence of any kind increases the risk of suicide. Alcohol or drug abuse is a significant factor in adolescent suicide. A concern about sexual orientation or being accepted as homosexual is a risk factor for suicide, especially among adolescents. Poor impulse control can lead to an increased tendency toward risk taking, which is a factor in suicide, especially among adolescents. Although economic problems and absence of a parent can both stress a family and its members, there is no research to support that either is a major factor in adolescent suicide.

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1."We want to attend a support group." 2."We never want to try to have a baby again." 3."We are going to try to adopt a child immediately." 4."We are okay, and we are going to try to have another baby immediately."

1. we want to attend a support group Rationale:A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that indicates positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process. Client Needs: Psychosocial Integrity Cognitive Ability: Applying Content Area: Maternity: Postpartum Health Problem: Maternity: Fetal Distress/Demise Integrated Process: Caring Priority Concepts: Coping, Family Dynamics Strategy(ies): Comparable or Alike Options, Subject

Which assessment question is appropriate when collecting a developmental history for an adolescent who is new to the pediatric practice? 1. "What grades do you get in school?" 2. "Have your wisdom teeth erupted yet?" 3. "What was your approximate height at 4 years of age?" 4. "What was your approximate weight at 5 years of age?"

1. what grades do you get in school Rationale: While all of these assessment questions are appropriate, only the question regarding scholastic performance (grades in school) is a question that is appropriate for a developmental history. Asking questions regarding wisdom tooth eruption and approximate height and weight at 4 and 5 years of age respectively is more appropriate when collecting a growth history.

The nurse is teaching an adolescent female client about growth changes that will occur during this stage of development. Which statement should the nurse include in the teaching session? 1. "Your peak rate of growth occurs by 12 years of age." 2. "Your peak rate of growth occurs by 14 years of age." 3. "Your last 50% of linear growth occurs during this stage of development." 4. "You can expect to gain up to 25% of your ideal adult weight during this stage of development."

1. your peak rate of growth occurs by 12 years of age Rationale: The nurse should educate the adolescent female client that her peak growth rate occurs by the age of 12 years. The peak growth rate for an adolescent male occurs by the age of 14 years. The adolescent can expect to gain 50% of his or her ideal adult weight and the last 25% of linear growth to occur during adolescence.

The mother of a preterm newborn is comparing the appearance of her preterm baby to the nearby full-term babies. She asks why her baby's skin appears so different. What is the best response for the nurse to provide? 1."A full term newborn has decreased brown fat stores." 2."A preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat." 3."A preterm baby has additional subcutaneous fat beneath the skin that is lost between 38 to 40 weeks." 4."The full term newborn has produced much more soft downy hair, giving the skin a more fuzzy appearance."

2. a preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat Rationale:The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against infection. The skin of a preterm newborn infant is immature in comparison with that of a term newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose heat because of their large body surface area in relation to their weight and because their posture is more relaxed with less flexion. Therefore, preterm newborn infants are less able to generate heat, which places them at risk for increased heat loss and increased fluid requirements. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Newborn Health Problem: Newborn: Preterm and Postterm Newborn Integrated Process: Nursing Process/Implementation Priority Concepts: Development, Tissue Integrity Strategy(ies): Strategic Words, Subject

The clinic nurse has conducted a health screening clinic to identify clients who are at risk for cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at lowest risk for developing this type of cancer? 1.A multiparity client 2.A single white client 3.A client with a history of chronic cervicitis 4.A client who had early, frequent intercourse with multiple sexual partners

2. a single white client Rationale:Risk factors associated with cervical cancer include early, frequent intercourse with multiple sexual partners; multiparity; chronic cervicitis; and a history of genital herpes or human papilloma. Cervical cancer also occurs with higher frequency in African Americans. Regarding the options provided, the single white client is at lowest risk for the development of cervical cancer. Client Needs: Health Promotion and Maintenance Cognitive Ability: Analyzing Content Area: Adult Health: Oncology Health Problem: Adult Health: Cancer: Cervical/Uterine/Ovarian Integrated Process: Nursing Process/Assessment Priority Concepts: Cellular Regulation, Sexuality Strategy(ies): Subject

A nursing instructor asks a nursing student to provide information about adolescents. Which statement made by the student indicates the need of further teaching? 1. "Adolescents have risk-taking behaviors." 2. "Adolescents accept their society and its values." 3. "Adolescents consider themselves invincible." 4. "Adolescents think of their parents as materialistic."

2. adolescents accept their society and its values Rationale: Adolescents tend not accept society and its values; they often question society and its values. Adolescents tend to take risks because they believe that they are invincible. Adolescents commonly consider their parents to be too narrow-minded or too materialistic.

The mother of a 16-year-old tells the nurse that she is concerned because her child sleeps about 8 hours every night and until noon every weekend. Which nursing response is most appropriate? 1."The child should not be staying up so late at night." 2."Adolescents need that amount of sleep every night." 3."If the child eats properly, that should not be happening." 4."The child probably is anemic and should eat more foods containing iron."

2. adolescents need that amount of sleep every night Rationale:An adolescent needs about 8 hours of sleep per night. During this age, with an increase in social activities, school commitments, and possibly work activities, it is important that the adolescent receive enough sleep at night. Nothing in the question indicates that the child is staying up at night. Adolescents need 8 hours of sleep each night, so diet is not a concern. Although anemia can cause fatigue, there is nothing in the question to indicate that the child has anemia, and the nurse should not attempt to diagnose a medical condition. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Developmental Stages: Adolescent Integrated Process: Communication and Documentation Priority Concepts: Development, Health Promotion Strategy(ies): Strategic Words, Therapeutic Communication Techniques

A married couple present to the preconceptual clinic with questions about how a fetus's chromosomal sex is established. What is the nurse's best response? 1. at ejaculation, chromosomal sex is established 2. at fertilization, chromosomal sex is established 3. at climax, chromosomal sex is established 4. at ovulation, chromosomal sex is established

2. at fertilization, chromosomal sex is established Rationale: Remember that the primary spermatocyte contains two sex chromosomes, one X chromosome and one Y chromosome, and the primary oocyte contains two sex chromosomes, both X chromosomes. During the first reduction division, two secondary spermatocytes are produced, one X and one Y, establishing X and Y cell lines. The X-bearing cell line is established during oogenesis. Female gametes will all be X bearing and male gametes will be either X or Y bearing. A female develops through the fertilization of the ovum by an X-bearing sperm producing an XX zygote; a male is produced through the fertilization of a Y-bearing sperm producing an XY zygote. Therefore, at fertilization, chromosomal sex is established. Chromosomal sex is not established at ovulation, ejaculation, or climax, so these choices are erroneous.

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1.Nalbuphine 2.Betamethasone 3.Rho(D) immune globulin 4.Dinoprostone vaginal insert

2. betamethasone Rationale:Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pharmacology: Maternity/Newborn: Lung Surfactant Health Problem: Maternity: Preterm Labor Integrated Process: Nursing Process/Analysis Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject

The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding? 1.Acyclovir 2.Ceftriaxone 3.Azithromycin 4.Penicillin G benzathine

2. ceftriaxone Rationale:Treatment for gonorrhea consists of antibiotic therapy, usually with ceftriaxone and doxycycline. Acyclovir is the treatment for genital herpes simplex virus; azithromycin is the treatment for Chlamydia infection, and penicillin G benzathine is the treatment for syphilis. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Foundations of Care: Infection Control Health Problem: Adult Health: Reproductive: Inflammation/Infections Integrated Process: Nursing Process/Planning Priority Concepts: Infection, Sexuality Strategy(ies): Subject

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1.Administer oxygen by face mask. 2.Clear and maintain an open airway. 3.Administer magnesium sulfate intravenously. 4.Assess the blood pressure and fetal heart rate.

2. clear and maintain an open airway Rationale:The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Implementation Priority Concepts: Care Coordination, Clinical Judgment Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? 1.Poor hygiene 2.Difficulty walking 3.Fear of the parents 4.Bald spots on the scalp

2. difficulty walking Rationale:Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Fear of the parents and bald spots on the scalp most likely are associated with physical abuse. Client Needs: Psychosocial Integrity Cognitive Ability: Analyzing Content Area: Health Assessment/Physical Exam: Assessment Techniques Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Interpersonal Violence Strategy(ies): Strategic Words, Subject

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? 1.Notify the primary health care provider. 2.Discontinue the infusion of oxytocin. 3.Place oxygen on at 8 to 10 L/minute via face mask. 4.Contact the client's primary support person(s) if not currently present.

2. discontinue the infusion of oxytocin Rationale:The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Dystocia Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Data in the Question, Strategic Words

An 80-year-old female patient lives with her son and his wife, and the couple's two young children. The patient was recently diagnosed with pancreatic cancer and is in the late stages of the disease. Her daughter-in-law has assumed the responsibility of the main caregiver and bathes, feeds, and dresses her mother-in-law everyday. The patient's son takes care of the children, cooks meals, and works outside of the home. The children read to their grandmother nightly. The nurse is visiting the patient and notices that, because of the patient's worsening illness, her son is spending more time at work to pay medical bills, her daughter-in-law appears fatigued and has lost 20 pounds, and her grandchildren have missed multiple days of school. The nurse knows that this scenario is best identified as which theory: 1. family stress theory 2. family systems theory 3. structural-functional theory 4. erikson's developmental theory

2. family systems theory Rationale: Family systems theory views the family as one unit and assesses how change in one individual affects the others. A balance is achieved between change and stability in this theory. Family stress theory defines the way that families react to and cope with stress as a family unit. Different levels of relationships develop as well as an increased number of reactions with the family. Erikson's developmental theory views the development of an individual rather than a family unit. Structural-functional theory, family members have specific roles and the family is viewed as a social system.

The community health nurse is preparing an educational class on ovarian cancer for a group of women. Which signs and symptoms should the nurse include in the presentation? Select all that apply. 1.Feeling hungry all the time 2.Having urinary urgency or frequency 3.Experiencing pelvic or abdominal swelling 4.Sense of feeling that something is "falling out" 5.Developing a macular-papular rash over the abdomen

2. having urinary urgency or frequency 3. experiencing pelvic or abdominal swelling Rationale:Signs and symptoms of ovarian cancer are often very subtle. Urinary urgency or frequency, abdominal or pelvic pain or swelling, vague gastrointestinal disturbances such as dyspepsia or gas, and unexplained weight loss are potential signs and symptoms and require further investigation. Hunger and a rash are not associated with this condition. A sense of something "falling out" may be reported by the client experiencing uterine prolapse. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Oncology Health Problem: Adult Health: Cancer: Cervical/Uterine/Ovarian Integrated Process: Teaching and Learning Priority Concepts: Cellular Regulation, Sexuality Strategy(ies): Subject

How does sexual identity aid psychosocial development in the adolescent? Select all that apply. 1. It helps them evaluate their own health. 2. It helps develop masculine and feminine behaviors. 3. It helps them feel a sense of admiration and acceptance. 4. It helps them develop decision-making and budgeting skills. 5. It helps them lessen the feeling that they are different from peers.

2. it helps develop masculine and feminine behaviors 5. it helps them lessen the feeling that they are different from peers Rationale: Physical evidence of maturity encourages the development of masculine and feminine behaviors and enhances sexual identity in the adolescent. Sexual identity assuages the adolescent's fear of being different from his or her peers. Adolescents depend on sexual clues because they want assurance of maleness or femaleness and do not wish to be different from their peers. Health identity helps the adolescent evaluate his or her own health. A group identity helps the adolescent develop a sense of being admired and accepted. A peer group provides the adolescent with a sense of belonging and approval and the opportunity to learn acceptable behavior. A family identity helps the adolescent develop decision-making and budgeting skills.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1.Providing comfort measures 2.Monitoring the fetal heart rate 3.Changing the client's position frequently 4.Keeping the significant other informed of the progress of the labor

2. monitoring the fetal heart rate Rationale:Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority. Client Needs: Physiological Integrity Cognitive Ability: Creating Content Area: Maternity: Intrapartum Health Problem: Maternity: Dystocia Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Maslow's Hierarchy of Needs Theory, Strategic Words

The nurse is educating a group of adolescents on sexuality and health. The nurse decides to include primary prevention strategies as a topic for discussion. Which intervention is considered a primary prevention strategy: 1. teaching about sexual dysfunction 2. teaching the correct use of condoms 3. diagnosing human papillomavirus (HPV) at an early stage 4. encouraging human immunodeficiency virus (HIV) testing after unprotected sex

2. teaching the correct use of condoms Rationale: Primary prevention strategies include strategies that are implemented to avoid the development of a disease. Teaching how to use condoms correctly can prevent the spread and occurrence of STIs and unwanted pregnancy. Diagnosis of HPV or other infections at an early stage is part of secondary prevention. HIV testing after unprotected sex is an example of secondary prevention. Teaching about sexual dysfunction is neither primary nor secondary prevention.

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1.Gently push the cord into the vagina. 2.Place the client in Trendelenburg's position. 3.Find the closest telephone and page the primary health care provider stat. 4.Call the delivery room to notify the staff that the client will be transported immediately.

2. place the client in Trendelenburg's position Rationale:When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the primary health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Prolapsed Umbilical Cord Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? 1."How often do you have sexual relations?" 2."Please share with me more about your concerns." 3."You are still young and have nothing to be concerned about." 4."You should not have a decline in testosterone until you are in your 80s."

2. please share with me more about your concerns Rationale:The nurse needs to establish trust when discussing sexual relationships with men. The nurse should open the conversation with broad statements to determine the true nature of the client's concerns. The frequency of intercourse is not a relevant first question to establish trust. Testosterone declines with the aging process. Client Needs: Psychosocial Integrity Cognitive Ability: Applying Content Area: Adult Health: Reproductive Integrated Process: Caring Priority Concepts: Communication, Sexuality Strategy(ies): Strategic Words, Therapeutic Communication Techniques

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? 1.Restrict food and fluids. 2.Reduce external stimuli. 3.Monitor blood glucose levels. 4.Maintain the client in a supine position.

2. reduce external stimuli Rationale:The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the primary health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs. Client Needs: Safe and Effective Care Environment Cognitive Ability: Creating Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1.Proteinuria of 3 + 2.Respirations of 10 breaths per minute 3.Presence of deep tendon reflexes 4.Urine output of 20 mL in an hour 5.Serum magnesium level of 4 mEq/L (2 mmol/L)

2. respirations of 10 breaths per minute 4. urine output of 20 mL in an hour Rationale:Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 mL per hour. Proteinuria of 3 + is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L). Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pharmacology: Maternity/Newborn: Tocolytics Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Perfusion, Reproduction Strategy(ies): Subject

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? 1.Frostbite 2.Skin breakdown 3.Arterial insufficiency 4.Venous insufficiency

2. skin breakdown Rationale:When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. The hypothermia blanket decreases the blood flow to pressure areas and can cause numbness, making it so that the client is not aware of damage to the skin. The temperature of the blanket is not cold enough to cause frostbite. Arterial insufficiency and venous insufficiency are not complications of hypothermia blanket use. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Neurological Health Problem: Adult Health: Neurological: Thermoregulation Integrated Process: Nursing Process/Assessment Priority Concepts: Safety, Thermoregulation Strategy(ies): Subject

A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. The nurse understands that because there are many kinds of potential abuse, she will need to assess for what type of factors? (Select all that apply.) 1. documentation of prescribed physical therapy sessions 2. skin breakdown in residents resulting from poor hygiene 3. unexplained bruising of residents 4. high ratio of overweight residents 5. altered cognitive function of residents

2. skin breakdown in residents resulting from poor hygiene 3. unexplained bruising of residents 5. altered cognitive function of residents Rationale: In addition to psychologic signs such as depression, signs of elder abuse include bruising from physical abuse and skin breakdown from neglect of hygiene and nutrition; frailty and decreased cognitive function are also risk factors for abuse. Overweight residents and following prescribed treatments are not indicators of abuse or neglect.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1.The client is a 35-year-old primigravida. 2.The client has a history of cardiac disease. 3.The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4.The client is a 20-year-old primigravida of average weight and height.

2. the client has a history of cardiac disease Rationale:Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Preterm Labor Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Comparable or Alike Options

A nurse involved in a health promotional program educates a group of adolescents at school. Which of these measures is the nurse unlikely to adopt? Select all that apply. 1. The nurse should ask if there are guns at the adolescent's house. 2. The nurse should treat the adolescents as small children. 3. The nurse should carry out an open discussion in a group. 4. The nurse should inquire about the health beliefs of adolescents. 5. The nurse should discuss alternatives to driving when under the influence of alcohol or drugs.

2. the nurse should treat the adolescents as small children 3. the nurse should carry out an open discussion in a group Rationale: During the educational program, the nurse should treat adolescents as adults, not as children. Any discussion with adolescents should be private and confidential. This helps the adolescents to express themselves freely without feeling embarrassed. The nurse should ask about the presence of guns in the home to evaluate any risk of homicide. The nurse should also ask about the health beliefs of adolescents. The nurse should discuss alternatives to driving when an adolescent is under the influence of drugs or alcohol.

A 17-year-old female patient tells the nurse that she believes she was born the wrong gender and feels like she is a male inside. The nurse knows that this statement indicates which sexual orientation: 1. the patient is a lesbian 2. the patient is transgender 3. the patient is bisexual 4. the patient is questioning her sexuality

2. the patient is transgender Rationale: Transgender youths have a gender identity that is in direct conflict with their assigned biologic gender. A lesbian is identified by sexual interest in another person of the same sex. While the patient could be questioning her sexuality, questioning often involves the journey that adolescents experience to determine their sexuality. Bisexual identity denotes sexual attraction toward both sexes.

A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient? 1. the patient may be a very demanding and particular person 2. the patient may have been the victim of an acute assault 3. the patient may be having an acute psychotic episode related to her mental illness 4. the patient may be abusing street drugs and needs a drug screening test

2. the patient may have been the victim of an acute assault Rationale: Refusing care from a caregiver of another gender, wanting easy escape access, and having poor eye contact all indicate that an assault may have occurred. Acute psychosis, use of street drugs, or being a demanding person does not elicit the signs of wanting to protect herself from others.

The nursing student is asked to discuss information related to the uterus with female high school students. Which statements by the nursing student are accurate? Select all that apply. 1."The uterus consists mostly of skeletal muscle." 2."The uterus is a pelvic organ when not pregnant." 3."The uterus weighs approximately 2.2 lb (1000 g) at term pregnancy." 4."The uterus weighs approximately 2 oz (60 g) in the nonpregnant state." 5."The uterus is composed of 3 layers: endometrium, myometrium, and perimetrium."

2. the uterus is a pelvic organ when not pregnant 3. the uterus weights approximately 2.2 lb (1000 g) at term pregnancy 4. the uterus weighs approximately 2 oz (60 g) in the nonpregnant state 5. the uterus is composed of 3 layers: endometrium, myometrium, and perimetrium Rationale:Before conception, the uterus is a small, pear-shaped cavity contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 2 oz (60 g) and has a capacity of about ⅓ oz (10 mL). At the end of pregnancy, the uterus weighs approximately 2.2 lb (1000 g) and has sufficient capacity for the fetus, placenta, and amniotic fluid. The uterus mostly consists of smooth muscle and is composed of 3 layers. The innermost layer is the endometrium, the middle layer is the myometrium, and the outer layer is the perimetrium. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Adult Health: Reproductive Integrated Process: Teaching and Learning Priority Concepts: Reproduction, Sexuality Strategy(ies): Subject

Which strategy needs to be employed while interviewing the adolescent as a part of her health-screening? 1. To start with more sensitive issues 2. To explain the limits of confidentiality 3. To ask more of close-ended questions 4. To interview the adolescent along with her parents

2. to explain the limits of confidentiality Rationale: Explaining the limits of confidentiality helps to obtain reports on physical or sexual abuse. It also helps to get others involved if the client is suicidal. As per the nursing care guidelines, interview should include open-ended questions, when possible, in order to obtain detailed information about the client. As per the guidelines, interview should begin with less sensitive issues followed by more sensitive ones. In order to ensure privacy, it is preferable to interview the adolescent in the absence of parents.

A client with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse is reviewing the laboratory results and determines that which magnesium level is within the therapeutic range? 1.1 mEq/L (0.5 mmol/L) 2.3 mEq/L (1.5 mmol/L) 3.5 mEq/L (2.5 mmol/L) 4.10 mEq/L (5 mmol/L)

3. 5 mEq/L Rationale:The therapeutic range for magnesium sulfate is 4 to 7 mEq/L (2 to 3.5 mmol/L); 1 mEq/L (0.5 mmol/L) and 3 mEq/L (1.5 mmol/L) are low values and 10 mEq/L (5 mmol/L) is an elevated value. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pharmacology: Maternity/Newborn: Magnesium Sulfate Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Evaluation Priority Concepts: Clinical Judgment, Evidence Strategy(ies): Subject

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1.A primiparous client who delivered 4 hours ago 2.A multiparous client who delivered 6 hours ago 3.A multiparous client who delivered a large baby after oxytocin induction 4.A primiparous client who delivered 6 hours ago and had epidural anesthesia

3. a multiparous client who delivered a large baby after oxytocin induction Rationale:The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Postpartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Strategic Words, Subject

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? 1.A private room across from the elevator 2.A semiprivate room across from the nurses' station 3.A private room 2 doors away from the nurses' station 4.A semiprivate room with another client who enjoys watching television

3. a private room 2 doors away from the nurses' station Rationale:A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A private room 2 doors away from the nurses' station is the best room assignment for this client. A private room across from the elevator and a semiprivate room across from the nurses' station may be noisy. A semiprivate room with a client who enjoys watching television would provide external stimuli, which must be kept minimal for the client with severe preeclampsia. The client with severe preeclampsia requires intense nursing observation and care. Client Needs: Safe and Effective Care Environment Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Planning Priority Concepts: Care Coordination, Safety Strategy(ies): Comparable or Alike Options, Strategic Words

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? 1.A man who has moderate hypertension 2.A man who has newly diagnosed cataracts 3.A woman who has advanced Parkinson's disease 4.A woman who has early diagnosed Lyme disease

3. a woman who has advanced parkinson's disease Rationale:Elder abuse includes physical, sexual, or psychological abuse; misuse of property; and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least 1 physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care. Client Needs: Safe and Effective Care Environment Cognitive Ability: Analyzing Content Area: Developmental Stages: Early Adulthood to Later Adulthood Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Assessment Priority Concepts: Interpersonal Violence, Safety Strategy(ies): Strategic Words, Subject

What is the most common cause of death among adolescents? 1. Suicide 2. Homicide 3. Accidents 4. Substance abuse

3. accidents Rationale: Accidents are the most common cause of death in adolescents; approximately 74% of all adolescent deaths are caused by accidents. Suicide is the third leading cause of death in adolescents. Homicide is the second leading cause of death in adolescents. Death by substance abuse affects 30% of adolescents.

What developmental nursing intervention should the nurse provide to promote safety among adolescents? Select all that apply. 1. Reducing the risk of physiologic falls 2. Guiding adolescents to make lifestyle modifications 3. Helping parents minimize risks to their adolescents' safety 4. Educating parents to protect their adolescents from life-threatening disease 5. Teaching parents to serve as role models by guiding expectations and providing education

3. helping parents minimize risks to their adolescents' safety 5. teaching parents to serve as role models by guiding expectations and providing education Rationale: The nurse should help parents take the initiative in ensuring the adolescent's safety. Adults serve as role models for adolescents; hence, the nurse should encourage parents to guide the adolescent's expectations and provide the child with adequate education. Nursing interventions to reduce the risk of physiologic falls is needed in elderly people. Interventions for lifestyle modification are needed in young adults. A family with an infant requires education to protect the infant from life-threatening disease.

The nurse is caring for a pediatric client who is recovering from abuse and neglect. Place in order of priority the interventions that the nurse performs. All options must be used. Select the correct sequence number for each item. 1.Clean and dress wounds 2.Provide emotional support 3.Administer pain medications 4.Ensure environmental safety

3. administer pain medications 1. clean and dress wounds 4. ensure environmental safety 2. provide emotional support Rationale:Interventions that may be performed by the nurse when caring for a client who is a victim of abuse or neglect include administering pain medications, providing wound care, using assistive devices to support sprains or fractures, educating the client and family about self-care, as well as education on support programs that provide awareness and emotional support. Also, ensuring that the victim is in a safe environment both in the hospital and when the victim is discharged is a priority. Administering pain medications, and cleaning and dressing wounds should be done first, followed by ensuring environmental safety and providing emotional support. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Foundations of Care: Special Populations Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Health Disparities Strategy(ies): Maslow's Hierarchy of Needs Theory, Strategic Words

A nurse educates a group of parents about the psychosocial changes of adolescents. Which statement made by parents indicates inadequate learning? 1. "Adolescents search for personal identity." 2. "Adolescents establish close peer relationships." 3. "Adolescents love their parents in every situation." 4. "Adolescents wish to be independent while keeping good family ties."

3. adolescents love their parents in every situation Rationale: Adolescents tend to love or hate their parents depending on the situations. Adolescent psychosocial development involves a search for personal identity. Adolescents may establish close peer relationships or remain socially isolated. Adolescents strive for emotionally independence from their parents while retaining family ties.

The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan? 1.Condoms should not be lubricated. 2.Use condoms whenever the partner seems "risky." 3.Always apply the condom before inserting the penis into the vagina. 4.Natural membrane condoms can be used because they are just as effective as latex.

3. always apply the condom before inserting the penis into the vagina Rationale:To be effective, condoms must be applied before any vaginal penetration occurs. A condom must be used with every sexual encounter if it is to be safe. A lubricated condom may be used to increase sensitivity of the glans. Natural membrane condoms are less effective than latex in preventing the spread of some STIs. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Foundations of Care: Infection Control Integrated Process: Teaching and Learning Priority Concepts: Infection, Sexuality Strategy(ies): Subject

The nurse is caring for a post-term, small for gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1.Urinary output 2.Total bilirubin levels 3.Blood glucose levels 4.Hemoglobin and hematocrit levels

3. blood glucose levels Rationale:The most common metabolic complication in the SGA newborn infant is hypoglycemia, which can produce central nervous system abnormalities and intellectual disabilities if not corrected immediately. Urinary output, although important, is not the highest priority action because the post-term SGA infant is typically dehydrated as a result of placental dysfunction. Hemoglobin and hematocrit levels are monitored because the post-term SGA infant exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Newborn Health Problem: Newborn: Preterm and Postterm Newborn Integrated Process: Nursing Process/Assessment Priority Concepts: Development, Glucose Regulation Strategy(ies): Strategic Words

How do adolescents establish group identity during psychosocial development? 1. By evaluating their own health with a feeling of well-being 2. By fostering their independence with balanced family structure 3. By building close peer relationships in order to achieve acceptance in the society 4. By achieving marked physical changes with masculine and feminine behaviors

3. by building close peer relationships in order to achieve acceptance in the society Rationale: By building close peer relationships, adolescents develop a sense of belonging, approval, and the opportunity to learn acceptable behavior. This action establishes group identity. An adolescent establishes health identity by evaluating his or her own health with a feeling of well-being. An individual establishes family identity by fostering his or her independence within a balanced family structure. The sound and healthy growth of an adolescent, with marked physical changes, helps the adolescent build sexual identity.

How does an adolescent establish group identity during psychosocial development? 1. By evaluating his or her own health with a feeling of well-being 2. By fostering his or her independence with balanced family structure 3. By building close peer relationships to achieve acceptance in the society 4. By achieving marked physical changes with masculine and feminine behaviors

3. by building close peer relationships to achieve acceptance in the society Rationale: By building close peer relationships, adolescents develop a sense of belonging, approval, and the opportunity to learn acceptable behavior. This behavior establishes the group identity. By evaluating his or her own health with a feeling of well-being, an adolescent establishes health identity. An individual establishes family identity by fostering their independence with balanced family structure. The sound and healthy growth of an adolescent with marked physical changes helps to build sexual identity.

The nurse educates an obese adolescent about healthy dietary habits and risk associated with obesity. Which statement by the adolescent indicates the need for further counseling? 1. "I should do exercise." 2. "I should play more outdoor games." 3. "I should watch more TV to reduce the stress." 4. "I should modify my diet and have lots of vegetables and water."

3. i should watch more TV to reduce the stress Rationale: The cause of obesity can be stress, but rather than watching TV to reduce the stress, some other activities like dancing, which involve physical movements, can be done. Any type of physical exercise helps in fat burning. Playing outdoor games not only is a physical exercise but also helps to reduce the stress. Reducing the consumption of fat-rich diet and replacing it with vegetables will reduce the amount of fat consumed by one and drinking high amount of water helps to detoxify the body.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1.Call the police. 2.Cut up the photograph and throw it away. 3.Call the nursing supervisor and report the occurrence. 4.Call the laboratory and ask for the name of the individual who sent the photograph.

3. call the nursing supervisor and report the occurrence Rationale:Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker and is an abusive behavior. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Leadership/Management: Ethical/Legal Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Implementation Priority Concepts: Health Care Law, Professionalism Strategy(ies): Strategic Words

The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? 1.Buspirone 2.Fluphenazine 3.Chlorpromazine 4.Prochlorperazine

3. chlorpromazine Rationale:Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Buspirone is an anxiolytic. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Neurological Health Problem: Adult Health: Neurological: Thermoregulation Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Thermoregulation Strategy(ies): Subject

Two female adults have an established long-term relationship and are attending parenting classes in anticipation of finalizing the adoption of their first baby. This couple demonstrates understanding of potential effects on family dynamics when making which statement? 1. any stress will finally be over once the baby arrives 2. our relationship with one another will not be affected 3. communication may be a challenge since we'll be busier 4. codependency is important to support each other

3. communication may be a challenge since we'll be busier Rationale: Addition of children, whether by birth, adoption, or blending families, increases the complexity of interactions in a family, introduces stress, and provides the potential for growth and maturation. Communication and interactions between family members are affected with the addition of new family members. Addition of any new family may place added stress on the relationship of the couple. Codependency refers to the dependence on another individual, usually family member, who actually contributes to negative behaviors, such as substance abuse.

The nurse is working with a couple in the infertility clinic. Which of the following should the nurse include in the teaching plan? 1. determine the time of menstruation 2. avoid intercourse before the appointments 3. determine the estimated time of ovulation 4. keep track of the number of times they have sex

3. determine the estimated time of ovulation Rationale: To become pregnant, the couple should have intercourse at the estimated time of ovulation. The amount of sex may increase the likelihood of pregnancy; however, ovulation is the most important component to achieving pregnancy. Determining the menstrual cycle will assist with calculating ovulation, which is necessary for pregnancy to occur. Avoiding intercourse before appointments is usually not necessary for infertility testing.

The nurse is assessing a 4-year-old child in a health clinic. Which of the following situations would cause the nurse to explore for possible abuse? 1. the caregiver reporting angry outbursts from the child while they were in a store 2. recent scrapes and bruises on both knees 3. different explanations of the injury from the child's parents 4. being brought to the clinic from daycare

3. different explanations of the injury from the child's parents Rationale: Inconsistent explanations from parents for how injuries occurred is a cause for further investigation. Being brought in from daycare, school, camp, or other public areas does not automatically indicate abuse. Scrapes on the knees are a common developmental injury for a 4-year-old. Angry outbursts or tantrums in children in this age-group are still expected developmental behaviors.

A female patient comes to the clinic at 8 weeks' gestation. She lives in a house beneath electrical power lines, which is located near an oil field. She drinks two caffeinated beverages a day, is a daily beer drinker, and has not stopped eating sweets. She takes a multivitamin and exercises daily. She denies drug use. Which finding in the history has the greatest implication for this patient's plan of care? 1. eating sweets may cause gestational diabetes or miscarriage 2. living near an oil field may mean the water supply is polluted 3. drinking alcohol should be avoided during pregnancy because of its teratogenic effects 4. electrical power lines are a potential hazard to the woman and her fetus

3. drinking alcohol should be avoided during pregnancy because of its teratogenic effects Rationale: Stages of development include the ovum, the embryo, and the fetus. The embryonic period lasts from the beginning of the fourth week to the end of the eighth week of gestation. Teratogenicity is a major concern because all external and internal structures are developing in the embryonic period. During pregnancy, a woman should avoid exposure to all potential toxins, especially alcohol, tobacco, radiation, and infectious agents. Living beneath power line or near an oil field is not teratogenic in itself. Stopping sweets can be addressed after the alcohol cessation is addressed.

A patient tells the nurse that she was a victim of domestic violence. Which action indicates that the patient is still having problems with intimacy? 1. the client avoids social situations with couples 2. the client begins taking a self-defense class 3. the client does not make eye contact with the nurse 4. the client lives alone

3. the client does not make eye contact with the nurse Rationale: Poor eye contact is common when patients have a poor self-image or feel shame associated with abuse. Self-defense classes may serve to increase a sense of power and control. Living alone is not associated with maladaptive behavior.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1.Warming the crib pad 2.Closing the doors to the room 3.Drying the infant with a warm blanket 4.Turning on the overhead radiant warmer

3. drying the infant with a warm blanket Rationale:Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact). Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Newborn Health Problem: Newborn: Thermoregulation Integrated Process: Nursing Process/Implementation Priority Concepts: Caregiving, Thermoregulation Strategy(ies): Strategic Words

The nurse is caring for a client in labor when a prolapsed umbilical cord is noted. In order of priority, which actions should the nurse take? All options must be used. Select the correct sequence number for each item. 1.Prepare for immediate birth. 2.Monitor fetal heart rate and tones. 3.Elevate the fetal presenting part that is lying on the cord by applying gloved finger pressure. 4.Administer oxygen 8 to 10 L/min via face mask. 5.Place the client in Trendelenburg or knee-chest position.

3. elevate the fetal presenting part that is lying on the cord by applying gloved finger pressure 5. place the client in Trendelenburg or knee-chest position 4. administer oxygen 8 to 10 L/min via face mask 2. monitor fetal heart rate and tones 1. prepare for immediate birth Rationale:If umbilical cord prolapse occurs, the cord is lying alongside or below the presenting part of the fetus and can be seen or felt in or protruding from the vagina. The nurse stays with the client and asks another nurse to call the primary health care provider immediately. The nurse must relieve cord pressure immediately so that the fetus receives adequate oxygenation. The nurse can relieve cord pressure by elevating the fetal presenting part that is lying on the cord; the nurse does this by quickly gloving the hand and inserting 2 fingers into the vagina to the cervix and exerting upward pressure on the presenting part. The nurse also relieves cord pressure by placing the client into an extreme Trendelenburg or modified Sims' position or a knee-chest position (a rolled towel is placed under the client's hip). The nurse administers oxygen, 8 to 10 L/min, by face mask to the client, monitors the fetal heart rate and fetal heart rate patterns, and assesses the fetus for hypoxia. The client is prepared for immediate birth (vaginal or cesarean). The nurse documents the event, actions taken, the client's response, and any additional pertinent information. The nurse never attempts to push the cord into the uterus. If the umbilical cord is protruding from the vagina, the cord is wrapped loosely in a sterile towel saturated with warm sterile normal saline. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Prolapsed Umbilical Cord Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing. 2.Make the decisions for the family. 3.Encourage expression of feelings, concerns, and fears. 4.Explain everything that is happening to all family members. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know they will not be abandoned by the nurse.

3. encourage expression of feelings, concerns, and fears 5. touch and hold the clients or family members hand if appropriate 6. be honest and let the client and family know they will not be abandoned by the nurse Rationale:The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate. Client Needs: Psychosocial Integrity Cognitive Ability: Analyzing Content Area: Developmental Stages: End-of-Life Care Integrated Process: Caring Priority Concepts: Family Dynamics, Palliation Strategy(ies): Therapeutic Communication Techniques

A pregnant woman of 30 weeks' gestation is admitted to the maternity unit in preterm labor. The woman asks the nurse about the purpose of betamethasone, which has been prescribed by the primary health care provider (PHCP). The nurse should tell the client that the medication will promote which action? 1.Delay delivery. 2.Prevent membrane rupture. 3.Enhance fetal lung maturity. 4.Stop the premature uterine contractions.

3. enhance fetal lung maturity Rationale:Betamethasone, a steroidal anti-inflammatory, increases the surfactant level and promotes lung maturation, thereby reducing the risk of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks of gestation, and if adequate amounts of lung surfactant are not present, respiratory distress and death of the newborn infant could result. Delivery should be delayed for at least 48 hours after administration of betamethasone to allow time for the lungs to mature. The other options are incorrect. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Pharmacology: Maternity/Newborn: Corticosteroids Health Problem: Maternity: Preterm Labor Integrated Process: Nursing Process/Implementation Priority Concepts: Development, Reproduction Strategy(ies): Comparable or Alike Options

At which stage does an adolescent develop abstract thinking? 1. Genital stage 2. Conventional reasoning 3. Formal operations period 4. Identity vs. role confusion

3. formal operations period Rationale: According to Piaget's moral development theory depicts, an adolescent develops abstract thinking during the formal operations period. According to Freud's genital stage, sexual urges reawaken and are directed to an individual outside the family circle. During the conventional reasoning stage, a person establishes his or her morals based on his or her own personal internalization of societal expectations. According to the identity versus role confusion stage, there is a marked preoccupation with appearance and body image.

The nurse is obtaining a sexual history of a 28-year-old woman. Which of the following questions is most useful in determining the patient's sexual orientation and risk factors? 1. how many partners have you had? 2. are you heterosexual, homosexual, or bisexual? 3. have you had sex with men, women, or both? 4. do you prefer to have sex with men or women?

3. have you had sex with men, women, or both? Rationale: This question is the most simply stated and will increase the likelihood of obtaining the relevant information about sexual orientation and possible risk factors associated with sexual activity. It is important to assess the number of partners to determine risk factors; however, the number of partners does not determine sexual orientation. A patient who prefers sex with women may also have intercourse at times with men. Many patients who have sex with both men and women do not identify themselves as homosexual or bisexual.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. 1.Back pain 2.Heavy vaginal bleeding 3.Increase in fundal height 4.Hard, board-like abdomen 5.Persistent abdominal pain 6.Early deceleration on the fetal heart monitor

3. increase in fundal height 4. hard, board-like abdomen 5. persistent abdominal pain Rationale:The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; hard, board-like abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): Subject

What are the physiologic changes noticed in an adolescent during puberty? Select all that apply. 1. Increase in the respiratory rate 2. Increase in the number of neurons 3. Increase in number of neural connections 4. Decrease in the basal body temperature gradually 5. Increase in serum iron, hemoglobin, and hematocrit

3. increase in number of neural connections 4. decrease in the basal body temperature gradually 5. increase in serum iron, hemoglobin, and hematocrit Rationale: During puberty, as a part of normal physiologic growth, there is proliferation of support cells that nourish the neurons along with increase in number of neural connections in the brain. The basal body temperature decreases gradually and reaches adult value by 12 years of age. The size and strength of heart, blood volume, systolic blood pressure, serum iron levels, hemoglobin, and hematocrit values increase whereas heart rate decreases and reaches adult value. The diameter and length of the lungs increase, but respiratory rate decreases gradually to reach the adult value by adolescence. The growth of neurons does not increase but slows to a more gradual rate by adolescence.

How does a family identity aid psychosocial development in the adolescent? 1. It helps the adolescent evaluate his or her health 2. It helps the adolescent develop a sense of admiration and acceptance 3. It helps the adolescent develop skills in decision-making and budgeting 4. It helps assuage the adolescent's feeling of being different from his or her peers

3. it helps the adolescent develop skills in decision-making and budgeting Rationale: When an adolescent cannot have a part-time job because of studies, school-related activities, or other factors, the parents can provide an allowance for clothing and incidentals, encouraging the child to develop decision-making and budgeting skills. Thus family identity aids the psychosocial development of the adolescent. A health identity helps the adolescent evaluate his or her own health. A group identity helps the adolescent develop a sense of being admired and accepted. Peer groups provide the adolescent with a sense of belonging, approval, and the opportunity to learn acceptable behavior. Sexual identity helps the adolescent assuage the fear of being different from his or her peers. Adolescents depend on sexual clues because of a need for assurance of their maleness or femaleness and the wish not to be different from their peers.

"But you don't understand" is a common statement associated with adolescents. What is the nurse's best response when hearing this? 1. "I don't understand what you mean." 2. "I do understand; I was a teenager once too." 3. "It would be helpful to understand; let's talk." 4. "It's you who should try to understand others."

3. it would be helpful to understand; lets talk Rationale: "It would be helpful to understand; let's talk" attempts to open the communication process. Reflecting the words, not the feelings, serves to entrench the communicant's position and does little to open the flow of communication. Saying "I was a teenager once too" shifts the focus away from the client. Telling the client to try to understand others is authoritative and closes the flow of communication.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1.Record the findings. 2.Massage the fundus. 3.Notify the obstetrician (OB). 4.Place the client in Trendelenburg's position.

3. notify the obstetrician (OB) Rationale:If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the OB. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Data in the Question, Strategic Words

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1.Document the findings. 2.Reassess the client in 2 hours. 3.Notify the primary health care provider (PHCP). 4.Encourage increased oral intake of fluids.

3. notify the primary health care provider (PHCP) Rationale:Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the PHCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Postpartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Strategic Words

A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position? 1.Prone 2.Supine 3.On the side 4.Reverse Trendelenburg's

3. on the side Rationale:If cord prolapse or compression is suspected, the client is immediately repositioned. Cord compression needs to be relieved to allow for adequate fetal oxygenation. The client may be turned to the side or the hips may be elevated to shift the fetal presenting part toward the diaphragm, thereby relieving cord compression. A hands-and-knees position may reduce compression on a cord that is entrapped behind the fetus. Prone, supine, and reverse Trendelenburg's positions will not shift the presenting part toward the diaphragm and could worsen the condition. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Prolapsed Umbilical Cord Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words, Subject

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1.Adhering to the mandatory abuse-reporting laws 2.Notifying the caseworker of the family situation 3.Removing the client from any immediate danger 4.Obtaining treatment for the abusing family member

3. removing the client from any immediate danger Rationale:Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions but are not the priority. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Mental Health Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Planning Priority Concepts: Interpersonal Violence, Safety Strategy(ies): Maslow's Hierarchy of Needs Theory, Strategic Words

The nurse has provided information about a safe shelter for a patient who is the victim of abuse. Which of the following is an additional intervention that the nurse must perform? 1. provide food vouchers for the patient's children 2. arrange for transportation to the shelter 3. report the abuse to the appropriate legal authority 4. other paperwork for medical assistance

3. report the abuse to the appropriate legal authority Rationale: All states have laws for mandatory reporting of suspected cases of abuse; it is not a violation of patient privacy to meet this requirement. Transportation, medical assistance, and emergency food are all helpful interventions, but there are no data indicating that such assistance is needed, and none of these interventions are mandatory.

Human sexuality is interrelated with a variety of other nursing concepts that may affect sexuality or be affected by healthy sexual functioning. Prompt diagnosis and treatment of potential concerns related to concept overlap is an important nursing function. Which other concept is most likely to overlap with sexuality? 1. gas exchange 2. stress 3. reproduction 4. pain

3. reproduction Rationale: The most obvious overlap between concepts is that of sexuality and reproduction. An example may be the use of contraceptives in order to avoid pregnancy. Women who are unable to conceive a child may experience emotional distress. A sexual relationship is likely to change as pregnancy advances. If a patient is feeling stress because of other life issues, this is likely to have a negative impact on his or her sexual relationships. The patient who has poor gas exchange may encounter challenges with sexual activity related to hypoxia. One physiologic barrier to healthy sexual functioning is pain. Both chronic pain and pain during intercourse can negatively affect a patient's sexual relationship.

The home health care nurse is providing instructions to a client after a vulvectomy. Which instruction should the nurse provide to the client? 1."You can engage in sexual activity in 2 weeks." 2."It is all right to begin to drive a car as long as you do not drive long distances." 3."Resume activities slowly, keeping in mind that walking is a beneficial activity." 4."It is important to rest and sit in a chair with your legs elevated as much as possible."

3. resume activities slowly, keeping in mind that walking is a beneficial activity Rationale:The client should resume activities slowly, and walking is a beneficial activity. Sexual activity is prohibited for approximately 4 to 6 weeks after surgery. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged sitting and standing. The client should not be instructed to sit in a chair as much as possible because pressure on the surgical site could lead to complications related to the surgery. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Adult Health: Oncology Health Problem: Adult Health: Cancer: Cervical/Uterine/Ovarian Integrated Process: Teaching and Learning Priority Concepts: Functional Ability, Sexuality Strategy(ies): Subject

Which of these behaviors does an adolescent exhibit? 1. Temper tantrums 2. Attempts to control situations 3. Synchronization of moral skills 4. Eagerness for formal education

3. synchronization of moral skills Rationale: Adolescents refine and synchronize physical, psychosocial, cognitive, and moral skills to become an accepted member of society. Toddlers tend to have temper tantrums. Toddlers also learn about how to control situations. Preschoolers refine the mastery of their bodies and eagerly await the beginning of formal education.

Which of these statements regarding adolescents are true? Select all that apply. 1. Homicide is infrequent among adolescents. 2. Suicide is the leading cause of death in adolescents. 3. The United States has the highest rate of teenage pregnancy. 4. Half of all adolescents have use alcohol by the end of the high school. 5. Anorexia nervosa and bulimia are two eating disorders found in adolescence.

3. the US has the highest rate of teenage pregnancy 5. anorexia nervosa and bulimia are two eating disorders found in adolescence Rationale: The United States has the highest annual rates of teenage pregnancy and childbearing among the industrialized nations. Anorexia nervosa and bulimia are two eating disorders found in adolescents. Homicide is not infrequent; it is the second leading cause of death among adolescents. Motor vehicle accidents, not suicide, are the leading cause of death among adolescents. Eighty-five percent of adolescents, not 50%, have used alcohol by the end of high school.

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation? 1.The client is hemorrhaging. 2.The client needs to increase oral fluids. 3.The client is experiencing normal lochia discharge. 4.The client's primary health care provider (PHCP) needs to be notified of the finding.

3. the client is experiencing normal lochia discharge Rationale:Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, the client is not hemorrhaging, not in need of increased fluids, and there is no need to contact the PHCP. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Postpartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Analysis Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Comparable or Alike Options, Data in the Question

The nurse in the family planning clinic is developing a teaching plan for a 22-year-old woman who was treated for pelvic inflammatory disease. What information should the nurse include in the plan of care? 1. the possibility of changes in secondary sex characteristics 2. the need to take the birth control pill 3. the increased risk of infertility 4. the importance of calculating monthly periods

3. the increased risk of infertility Rationale: Pelvic inflammatory disease may cause scarring of the fallopian tubes and result in difficulty in fertilization or implantation of the fertilized egg. Because ovarian function is not affected, the patient will not require hormone therapy, have irregular menstrual cycles, or experience changes in secondary sex characteristics.

What characteristics develop in an adolescent according to Piaget's theory of cognitive development? Select all that apply. 1. The individual shows animism. 2. The individual is able to understand the process of reversibility. 3. The individual develops the ability to reason with respect to possibilities. 4. The individual develops action patterns for dealing with the environment. 5. The individual demonstrates feelings and behaviors characterized by self-consciousness.

3. the individual develops the ability to reason with respect to possibilities 5. the individual demonstrates feelings and behaviors characterized by self-consciousness Rationale: According to Piaget's theory of cognitive development, during the formal operations stage, an adolescent develops the capacity to reason with respect to possibilities. They also show egocentrism and demonstrate feelings and behaviors characterized by self-consciousness. During the preoperational stage, a child between the ages of 2 and 7 demonstrates animism, in which they personify objects. According to Piaget's theory, reversibility is one of the primary characteristics that develop in a child between 7 and 11 years old. Infants develop a schema or action pattern for dealing with the environment.

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the primary health care provider (PHCP). The nurse should tell the woman to call the PHCP if which occurs? 1.Urine test is negative for protein. 2.Fetal movements are more than 4 per hour. 3.Weight increases by more than 1 pound in a week. 4.The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.

3. weight increases by more than 1 pound in a week Rationale:The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (3 or fewer movements per hour) may indicate fetal compromise and should be reported. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Implementation Priority Concepts: Caregiving, Perfusion Strategy(ies): Subject

The nurse planning to assess the function of a family would ask 1. who are the members of your family 2. who lives with you 3. who does the grocery shopping 4. how old are the members of your family

3. who does the grocery shopping Rationale: The question "Who does the grocery shopping?" would provide information about family functioning and how individuals actually behave in relation to one another. The question "Who lives with you?" would provide information about the structure of the family. The question "Who are the members of your family?" provides information about the structure of the family. The question "How old are the members of your family?" would provide information about family development.

A pregnant client being admitted to the labor room tells the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/minute and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? 1.Place the woman in a high-Fowler's position. 2.Palpate and evaluate contractions while administering a tocolytic. 3.Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline. 4.Start an intravenous (IV) line with fluids to be administered at a keep-vein-open (KVO) rate only.

3. wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline Rationale:When an umbilical cord is protruding, nursing actions are immediately directed at reducing cord compression and facilitating delivery of the fetus. The cord is wrapped loosely in a sterile towel saturated with warm normal saline to prevent it from drying out and becoming compressed. The client is placed in an extreme Trendelenburg's or modified Sims' position or knee-chest position to reduce compression. A tocolytic is used for inadequate uterine relaxation. IV solutions are administered at a rate greater than a KVO rate. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Prolapsed Umbilical Cord Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Reproduction Strategy(ies): Subject

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? 1."I don't like my figure anymore. My clothes are all too tight." 2."I don't like my breasts anymore. These silver lines are ugly." 3."I don't like my stomach anymore. That brown line is disgusting." 4."I don't like my face anymore. I always look like I have been crying."

4. I dont like my face anymore. I always look like I have been crying. Rationale:In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments should not be ignored, the need for follow-up is not urgent. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Perfusion, Reproduction Strategy(ies): Data in the Question, Strategic Words

A nursing instructor asks a nursing student about the development of adolescents according to Piaget's theory. Which statement made by the student indicates a need for further education? Select all that apply. 1. "Adolescents exhibit risk-taking behaviors." 2. "Adolescents consider their thoughts to be unique." 3. "Adolescents have a prevalence of egocentric thought." 4. "Adolescents emphasize using knowledge to achieve a goal." 5. "Adolescents have the ability to recognize different answers for different situations."

4. adolescents emphasize using knowledge to achieve a goal 5. adolescents have the ability to recognize different answers for different situations Rationale: William Perry suggested that adults use their knowledge to achieve a goal that is not seen in adolescents. Postformal thought is the fifth stage of Piaget's theory, which states that adults demonstrate the ability to recognize that different situations have different solutions. Adolescents lack this ability. During the formal operations period of Piaget's theory, adolescents have a sense of invulnerability, which leads to risk-taking behaviors. They consider their thoughts to be unique and have a prevalence of egocentric thought.

A 16-year-old client 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? 1.Encourage the client to rest and read. 2.Encourage the parents to room in with the client. 3.Allow the family to bring in the client's favorite computer games. 4.Allow the client to interact with others in his or her same age group.

4. allow the client 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 client from the peer group. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Developmental Stages: Adolescent Health Problem: Pediatric-Specific: Appendicitis Integrated Process: Caring Priority Concepts: Development, Health Promotion Strategy(ies): Comparable or Alike Options, Strategic Words

A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse should plan to address which client problem? 1.Pain related to fluid accumulation in the scrotum 2.Uneasiness related to inability to reduce scrotal swelling 3.Guilt related to the possibility of sterility secondary to scrotal swelling 4.Altered body appearance related to change in the appearance of the scrotum

4. altered body appearance related to change in the appearance of the scrotum Rationale:Altered body appearance is a problem when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. Pain may apply but does not correlate with the information in the question. There are no data in the question that uneasiness, inability to reduce scrotal swelling, or sterility is a client concern. Client Needs: Psychosocial Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Renal and Urinary Health Problem: Adult Health: Renal and Urinary: Inflammation/Infections Integrated Process: Nursing Process/Planning Priority Concepts: Coping, Sexuality Strategy(ies): Subject

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1."Oh, really? I will discuss this situation with your son." 2."Let's talk about the ways you can manage your time to prevent this from happening." 3."Do you have any friends who can help you out until you resolve these important issues with your son?" 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. as a nurse, i am legally bound to report abuse. i will stay with you while you give the report and help find a safe place for you to stay. Rationale:The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Leadership/Management: Ethical/Legal Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Implementation Priority Concepts: Health Care Law, Interpersonal Violence Strategy(ies): Comparable or Alike Options, Data in the Question, Strategic Words

A 15-year-old is injured and sustains a fractured jaw. The fractured jaw has been surgically wired, and the primary health care provider (PHCP) has prescribed a full liquid diet. Which nursing action would best promote compliance and provide an adequate nutrient value with the full liquid diet for this teenager? 1.Offer chocolate milkshakes between meals. 2.Explain the importance of good nutrition to the teenager. 3.Offer commercial nutritional supplements 4 to 6 times per day. 4.Ask the teenager for food preferences and liquefy these foods using a blender.

4. ask the teenager for food preferences and liquefy these foods using a blender Rationale:A 15-year-old may have difficulty maintaining compliance with a diet that is only liquids. To encourage compliance, it is important to have the teenager participate in as much decision making about the diet as possible. Although liquefied foods may be unappealing under many circumstances, the nutrient value is unchanged. The teenager will have an opportunity to "eat" the same foods that he or she was eating before the jaw fracture. Providing chocolate milkshakes between meals may be beneficial but does not offer the teenager any choices. Teenagers may or may not respond to reasoning and explanations of the importance of good nutrition. Commercial supplements also are beneficial nutritional sources but will not be effective unless the client is willing to drink them. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Developmental Stages: Adolescent Health Problem: Pediatric-Specific: Fractures Integrated Process: Nursing Process/Implementation Priority Concepts: Development, Nutrition Strategy(ies): Strategic Words, Subject

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1.Provide oral fluids and begin fundal massage. 2.Begin hourly pad counts and reassure the client. 3.Elevate the head of the bed and assess vital signs. 4.Assess for hypovolemia and notify the primary health care provider (PHCP).

4. assess for hypovolemia and notify the primary health care provider (PHCP) Rationale:Symptoms of hypovolemia include cool, clammy, pale skin; sensations of anxiety or impending doom; restlessness; and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the PHCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Maternity: Postpartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance Strategy(ies): Data in the Question, Steps of the Nursing Process, Strategic Words

The nurse notices that the patient who was just admitted to the mental health unit avoids eye contact, looks down when talking, and has multiple bruises all over her body. The patient's spouse arrives and the nurse overhears them arguing. The patient's spouse becomes angry during the argument and verbally threatens the patient. What should the nurse do? 1. physically intervene in the argument and try to help the couple resolve it 2. ask the physician for an order for a social work consult 3. call 911 4. attempt to get the patient alone and assess for intimate partner violence (IPV)

4. attempt to get the patient alone and assess for intimate partner violence (IPV) Rationale: When there is sufficient evidence of IPV, the nurse should attempt to assess the patient in a private area so further questioning can be conducted. The nurse can assure the patient that no one deserves abuse. Phone numbers and groups of organizations assisting those in abusive situations can be given to the patient. The nurse can also assist the patient in contacting the police. Option A is incorrect because further assessment needs to be conducted, and calling 911 could anger the spouse further. Option B is incorrect because physically intervening in an argument could pose a danger to the nurse. Option C is incorrect. Although a social work consult may be necessary, that step may be taken later after the nurse conducts a thorough assessment and ensures that the patient is safe.

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1.Peripads 2.Tape measure 3.Reflex hammer 4.Blood pressure cuff

4. blood pressure cuff Rationale:Methylergonovine is an oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. The client's blood pressure also should be monitored during the administration of the medication. Methylergonovine is administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension occurs. Peripads, a tape measure, and a reflex hammer are not priority items. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Postpartum Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the primary health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1.Bear down. 2.Breathe rapidly. 3.Hold your breath. 4.Push with each contraction.

4. breathe rapidly Rationale:During a precipitous labor, when the infant's head crowns the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and the fetus. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Intrapartum Health Problem: Maternity: Precipitous Labor and Delivery Integrated Process: Nursing Process/Implementation Priority Concepts: Caregiving, Perfusion Strategy(ies): Comparable or Alike Options, Subject

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1.Tongue blade 2.Percussion hammer 3.Potassium chloride injection 4.Calcium gluconate injection

4. calcium gluconate injection Rationale:Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest priority item. Potassium chloride is not related to the administration of magnesium sulfate. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Safety Strategy(ies): Data in the Question, Strategic Words

The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? 1."Caution should be used when straddling my infant on a hip." 2."Vital signs should be taken daily to check for bladder infection." 3."Catheterization will be necessary when my infant does not void." 4."Circumcision has been delayed to save tissue for surgical repair."

4. circumcision has been delayed to save tissue for surgical repair Rationale:Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised, because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pediatrics: Renal and Urinary Health Problem: Pediatric-Specific: Urologic Structural Abnormalities Integrated Process: Nursing Process/Evaluation Priority Concepts: Client Education, Elimination Strategy(ies): Subject

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 15 minutes. How should the nurse respond to this finding initially? 1.Document the finding. 2.Encourage the client to ambulate. 3.Encourage the client to increase fluid intake. 4.Contact the primary health care provider (PHCP) and inform the PHCP of this finding.

4. contact the PHCP and inform the PHCP of this finding 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. If the client is experiencing excessive bleeding, the nurse should contact the PHCP in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Implementation Priority Concepts: Clotting, Reproduction Strategy(ies): Abnormality Exists, Data in the Question, Strategic Words

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? 1.Increased heart rate and increased blood pressure 2.Increased heart rate and decreased blood pressure 3.Decreased heart rate and increased blood pressure 4.Decreased heart rate and decreased blood pressure

4. decreased heart rate and decreased blood pressure Rationale:Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Adult Health: Neurological Health Problem: Adult Health: Neurological: Thermoregulation Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Thermoregulation Strategy(ies): Subject

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1.Hematuria and pyuria 2.Dysuria and proteinuria 3.Hematuria and urgency 4.Dysuria and penile discharge

4. dysuria and penile discharge Rationale:Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated with kidney dysfunction. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Renal and Urinary Health Problem: Adult Health: Renal and Urinary: Inflammation/Infections Integrated Process: Nursing Process/Assessment Priority Concepts: Infection, Sexuality Strategy(ies): Subject

A just-delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism? 1.Radiation 2.Convection 3.Conduction 4.Evaporation

4. evaporation Rationale:The newborn can lose heat through radiation, convection, conduction, and evaporation. Heat is lost through the process of evaporation when the newborn is not dried thoroughly. Drying the infant's head assists with heat retention by preventing the mechanism of evaporation. Heat loss from radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Placing a warm blanket on the table assists with preserving body temperature. Warming room air relates to the heat loss mechanism of conduction. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Maternity: Newborn Health Problem: Newborn: Thermoregulation Integrated Process: Nursing Process/Implementation Priority Concepts: Development, Thermoregulation Strategy(ies): Data in the Question, Subject

Which of these thoughts in an adolescent corresponds to a sense of "invulnerability"? 1. "My doll will cry if I will ignore her for too long." 2. "I need to look beautiful because everyone has their eyes on me." 3. "If my football gets deflated, I can reinflate it." 4. "Even if I drive my car at 120 km per hour, nothing will happen to me."

4. even if i drive my car at 120 km per hour, nothing will happen to me Rationale: An adolescent who thinks that risky driving does not pose a threat demonstrates a sense of " invulnerability." A preschooler concerned about his or her doll demonstrates animism. When a teen believes that everyone is paying attention to him or her, this thought denotes the feeling of personal fable. When an individual thinks that a deflated football can be inflated again, this thought shows the concept of reversibility.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1.Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Evidence of bleeding, such as in the gums, petechiae, and purpura

4. evidence of bleeding, such as in the gums, petechiae, and purpura Rationale:Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Comparable or Alike Options, Strategic Words, Subject

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? 1.Cerebrum 2.Cerebellum 3.Hippocampus 4.Hypothalamus

4. hypothalamus Rationale:Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Neurological Health Problem: Adult Health: Neurological: Thermoregulation Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Thermoregulation Strategy(ies): Subject

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms? 1."Well, a picture paints a thousand words." 2."You just felt like destroying your textbooks?" 3."Your parents and teachers are very concerned about your drawings." 4."I am concerned about you. Are you now or have you ever been abused?"

4. i am concerned about you. are you now or have you ever been abused? Rationale:The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. The remaining options are insensitive, not focused on the possible sexual abuse, or too indirect to be useful. Client Needs: Psychosocial Integrity Cognitive Ability: Applying Content Area: Mental Health Health Problem: Mental Health: Abusive Behaviors Integrated Process: Communication and Documentation Priority Concepts: Interpersonal Violence, Sexuality Strategy(ies): Subject, Therapeutic Communication Techniques

A nursing instructor asks a nursing student about how to teach an adolescent about his or her development capacity. Which statement made by the student indicates a need for further education? 1. "I should use teaching as a collaborative activity." 2. "I should use problem-solving to help adolescents make choices." 3. "I should help an adolescent learn about his or her feelings and need for self-expression." 4. "I should make a decision about the health and health promotion of an adolescent."

4. i should make a decision about the health and health promotion of an adolescent Rationale: A nurse should allow adolescents to make decisions about health and health promotion; the nurse should not make the decision for the child. The nurse should use teaching as a collaborative activity. The nurse should use problem-solving to help adolescents make choices and help an adolescent to learn about feelings and need for self-expression.

A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? 1."I can douche anytime I want." 2."I can wear my tight-fitting jeans." 3."I should avoid the use of condoms." 4."I should wear underwear with a cotton panel liner."

4. i should wear underwear with a cotton panel liner Rationale:Wearing items with a cotton panel liner allows for air movement in and around the genital area. Douching is to be avoided. Wearing tight clothing can irritate the genital area and does not allow for air circulation. Condoms should be used to minimize the spread of genital tract infections. Client Needs: Health Promotion and Maintenance Cognitive Ability: Evaluating Content Area: Maternity: Antepartum Health Problem: Maternity: Infections/Inflammation Integrated Process: Nursing Process/Evaluation Priority Concepts: Infection, Sexuality Strategy(ies): Subject

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction? 1."I'll check his temperature." 2."I'll give him medication so he'll be comfortable." 3."I'll check his voiding to be sure there's no problem." 4."I'll let him decide when to return to his play activities."

4. i'll let him decide when to return to his play activities Rationale:Cryptorchidism is a condition in which 1 or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Pediatrics: Renal and Urinary Health Problem: Pediatric-Specific: Urologic Structural Abnormalities Integrated Process: Teaching and Learning Priority Concepts: Client Education, Safety Strategy(ies): Negative Event Query, Strategic Words

The nurse is in the emergency department is caring for a patient who was a victim of sexual assault. Which statement by the nurse is most helpful for the patient following a sexual assault? 1. i'm sorry you were hurt. follow up with your provider on monday for forensic testing 2. im sorry you were hurt. i am amazed at how good you look for what you went through 3. im sorry you were hurt. i hope were able to learn from this situation 4. im sorry you were hurt. it took a lot of courage for you to come to the emergency room

4. im sorry you were hurt. it took a lot of courage for you to come to the emergency room Rationale: Victims are often afraid to come forward and need support and encouragement. Option A does not address the immediacy of the situation. Option B evades the issue. Option C is an accusation statement and should be avoided.

A 20-year-old woman comes for preconceptual counseling. She wants to get pregnant soon. Which of the following health-promoting habits would have the highest priority at this time? 1. stopping all caffeine 2. getting daily exercise 3. avoidance of sweets 4. immediate tobacco cessation

4. immediate tobacco cessation Rationale: Psychosocial factors affecting pregnancy include smoking, excessive use of caffeine, alcohol and drug abuse, psychologic status including impaired mental health, an addictive lifestyle, spouse abuse, and noncompliance with cultural norms. Immediate tobacco cessation would be the highest priority because continued smoking could be teratogenic if the woman should become pregnant. Smoking causes vasoconstriction which restricts the amount of oxygen and nutrients to the rapidly growing fetus. Daily exercise promotes health but would not be the highest priority among these factors. Stopping caffeine and avoiding sweets are important and can be addressed after tobacco cessation.

The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures? 1."I do not need to abstain from sexual intercourse." 2."I need to use vaginal creams after I douche every day." 3."I need to douche and perform a sitz bath 3 times a day." 4."It may be necessary to have a cesarean section for delivery."

4. it may be necessary to have a cesarean section for delivery Rationale:If a woman has an active lesion, either recurrent or primary at the time of labor, delivery should be by cesarean section. Women are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the woman should continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated, and the genital area should be kept clean and dry to promote healing. Client Needs: Safe and Effective Care Environment Cognitive Ability: Evaluating Content Area: Maternity: Antepartum Health Problem: Maternity: Infections/Inflammation Integrated Process: Teaching and Learning Priority Concepts: Infection, Sexuality Strategy(ies): Comparable or Alike Options, Subject

The nurse is assessing a family composed of a married couple with three children, one from the wife's previous marriage and two from the union of this couple. This couple would be considered what type of family? 1. same-sex family 2. single-parent family 3. nuclear family 4. married-blended family

4. marriage-blended family Rationale: This family is a married-blended family with one child from the wife's previous marriage and two children from the union of this couple. A nuclear family refers to the traditional male and female core family with one or more children. A same-sex family is one where two individuals of the same sex have an established relationship and commitment; this may be referred to as a homosexual couple or family, but the preferred term is same-sex family. A single-parent family refers to a family with one adult and one or more children.

Which period of Piaget's theory explains self-consciousness in an adolescent? 1. Period I 2. Period II 3. Period III 4. Period IV

4. period IV Rationale: In period IV of Piaget's theory, an adolescent demonstrates feelings and behaviors characterized by self-consciousness. During period I, an infant develops a schema or action pattern for dealing with the environment. During period II, the child demonstrates animism, in which he or she personifies objects. While going through period III, the child thinks about an action that earlier was performed physically.

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1.Maternal fatigue 2.Coordinated uterine contractions 3.Progressive changes in the cervix 4.Persistent nonreassuring fetal heart rate

4. persistent nonreassuring fetal heart rate Rationale:Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Intrapartum Health Problem: Maternity: Dystocia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Comparable or Alike Options, Subject

To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement? 1.Dry the newborn's head thoroughly. 2.Turn the thermostat in the room to 70º F. 3.Place the newborn near the nursery window. 4.Place a warm blanket on the examining table before placing the newborn on the table.

4. place a warm blanket on the examining table before placing the newborn on the table Rationale:Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Placing a warm blanket on the table assists with preserving body temperature. Drying the infant's head assists with heat retention by preventing the mechanism of evaporation. Warming room air relates to the heat loss mechanism of conduction. Heat loss from radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Client Needs: Health Promotion and Maintenance Cognitive Ability: Applying Content Area: Maternity: Newborn Health Problem: Newborn: Thermoregulation Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Thermoregulation Strategy(ies): Subject

The nurse working with a family to prepare them for discharge of the father after a stroke would help them to address the things they can control, such as 1. maturity of individuals 2. economic state of society 3. genetic inheritance 4. psychological defenses

4. psychological defenses Rationale: Nursing intervention can help the family with psychological defense strategies, which are the ways a family reacts to the stress of a member whose health status has changed. This nurse would use knowledge of family stress theory in differentiating things the family can control and things the family cannot control. The family has no control over the economic state of society. The family would have no control over genetic inheritance in this situation. The family would have no control over the maturity of the individuals involved. Psychological defense strategies could promote adaptation of the family unit.

The nurse has just administered ibuprofen to a child with a temperature of 102° F (38.8° C). The nurse should also take which action? 1.Withhold oral fluids for 8 hours. 2.Sponge the child with cold water. 3.Plan to administer salicylate in 4 hours. 4.Remove excess clothing and blankets from the child.

4. remove excess clothing and blankets from the child Rationale:After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water but not cold water, because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin (a salicylate) is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Pediatrics: Metabolic/Endocrine Health Problem: Pediatric-Specific: Fever Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Thermoregulation Strategy(ies): Subject

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? 1.Urinary output of 20 mL 2.Deep tendon reflexes of 2+ 3.Fetal heart rate of 120 beats/minute 4.Respiratory rate of 10 breaths/minute

4. respiratory rate of 10 breaths/minute Rationale:Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the health care provider needs to be notified and continuation of the medication needs to be reassessed. A urinary output of 20 mL in a 30-minute period is adequate; less than 30 mL in 1 hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is within normal limits for a resting fetus. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Gas Exchange, Safety Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? 1.Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." 2.Suggest to the client and daughter-in-law that they consider a nursing home for the client. 3.Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. 4.Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

4. suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center Rationale:Assisting clients and families to become aware of available community support systems is a role and responsibility of the nurse. Observing that the client has begun to be confined to his room makes it necessary for the nurse to intervene legally and ethically, so option 3 is not appropriate and is passive in terms of advocacy. Option 2 suggests committing the client to a nursing home and is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of the nursing care required. Option 1 is incorrect and judgmental. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Developmental Stages: Early Adulthood to Later Adulthood Health Problem: Mental Health: Abusive Behaviors Integrated Process: Nursing Process/Implementation Priority Concepts: Ethics, Health Care Law Strategy(ies): Strategic Words

Which of these characteristics are found in an adolescent according to Erikson's theory of psychosocial development? Select all that apply. 1. The adolescent concentrates on work and play. 2. The adolescent develops autonomy by making choices. 3. The adolescent develops a conscience. 4. The adolescent is concerned about his or her appearance and body image. 5. The adolescent acquires a sense of identity by participating in decision-making.

4. the adolescent is concerned about his or her appearance and body image 5. the adolescent acquires a sense of identity by participating in decision-making Rationale: According to Erikson's theory, an adolescent has a marked preoccupation with his or her appearance and body image. Also during this stage, the adolescents develop a sense of identity by participating in decision-making. A toddler develops his or her autonomy by making choices. A child between three and six years old develops a superego or conscience. According to Erikson's theory of psychosocial development, ages 3-5 years old concentrates on work and play, not adolescents.

The nurse is trying to help a 5-year-old from an abusive home learn how to print her name. The child bursts out crying and says, "I'll never learn this because I'm stupid." The nurse assesses this to mean which of the following? 1. the child should be told that the task is too difficult 2. the child may be developmentally delayed 3. the child has a low IQ 4. the child has a poor self image

4. the child has a poor self image Rationale: Abused children often have low self-esteem because they often put down, neglected, and told they are stupid by their abusers. The other options are not associated with child abuse.

The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1.Urinary output has increased. 2.Dependent edema has resolved. 3.Blood pressure reading is at the prenatal baseline. 4.The client complains of a headache and blurred vision.

4. the client complains of a headache and blurred vision Rationale:If the client complains of a headache and blurred vision, the PHCP should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Maternity: Antepartum Health Problem: Maternity: Gestational Hypertension/ Preeclampsia and Eclampsia Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Comparable or Alike Options

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1.The mother is observed talking to the newborn. 2.The mother performs cord care for the newborn. 3.The mother verbalizes discomfort with the new role of motherhood. 4.The mother requests that the nurse feed the newborn because she is feeling fatigued.

4. the mother requests that the nurse feed the newborn because she is feeling fatigued Rationale:The nurse should be alert to maladaptive interaction in the maternal-infant bonding processes. If the nurse notes that the mother is avoiding interaction with the newborn or is avoiding caring for the newborn, the nurse should suspect the potential for a maladaptive interaction. Talking to the newborn or willingness to perform cord care does not indicate a maladaptive response. Expressing discomfort with the new role of motherhood is a normal, expected process, and it is important for the mother to verbalize concerns. Client Needs: Psychosocial Integrity Cognitive Ability: Analyzing Content Area: Maternity: Postpartum Health Problem: Mental Health: Coping Integrated Process: Caring Priority Concepts: Coping, Family Dynamics Strategy(ies): Subject

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? 1."You will be isolated from your newborn infant after delivery." 2."Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." 3."There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." 4."You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

4. you will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed Rationale:With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures should be obtained from potentially exposed newborn infants on the day of delivery. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Maternity: Antepartum Health Problem: Maternity: Infections/Inflammation Integrated Process: Nursing Process/Implementation Priority Concepts: Infection, Sexuality Strategy(ies): Subject

A 13-year-old female adolescent comes to the pediatric clinic, and her body mass index (BMI) is found to be 21. Compare the adolescent's BMI to the body mass index-for-age percentiles for girls age 2 to 20 years and determine what percentile this adolescent falls under. Record your answer using a whole number. ___th percentile

75th percentile Rationale: Find the age of 13 along the horizontal scale at the bottom of the graph. Follow the line vertically up the graph to the client's BMI of 21. The two lines bifurcate on the line for the 75th percentile.