Health Promotion & Maintenance

A physician prescribes an oral antidiabetic medication and weekly glucose monitoring for a 42-year-old male client recently diagnosed with type 2 diabetes. The client is moderately overweight and has a poor diet and a stressful job. He asks how his diagnosis will affect his life. Which response is most appropriate?

"I'll refer you to a diabetes nurse specialist. She'll help you develop a plan." Explanation: A referral to a nurse specialist who can develop an ongoing relationship and spend more time assessing the client's personal needs and developing a workable plan with him would be most appropriate. Although the medication does help to maintain steady glucose levels, this response ignores the other factors contributing to the client's poor health habits. Telling the client that he won't have to make any lifestyle changes is inappropriate, as is suggesting he change careers.

During a well-baby visit, a 2-month-old infant receives diphtheria, tetanus, acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How should the nurse respond?

"This vaccine protects against bacterial infections, such as meningitis and bacterial pneumonia." Explanation: The Hib vaccine provides protection against serious childhood infections caused by H. influenzae type B virus, such as meningitis and bacterial pneumonia. The influenza virus vaccine provides immunity to various strains of the influenza virus. The Heptavax vaccine prevents infection by the hepatitis B virus. Chickenpox is caused by the varicella virus; a chickenpox vaccine is now available.

TB/ Mantouix

(purified protein derivative (PPD) of the tuberculin bacilli) A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat, circumscribed area, to be considered positive

The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?

- Enlarged breast tissue Explanation: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full- term, well-developed neonates and aren't related to estrogen.

INR

0.76-1.27 ( if on coumadin INR 2-3)

Magnesium (Mg)

1.5- 2.5 mEg/L

BUN urea nitrogen

10-20 mg/dL

Coagulation , PT

11-12.5 seconds

A 34-year-old woman is in labor and the baby is full term. The nurse is checking the fetal heart rate. What range of fetal heart rates would reassure the nurse of appropriate fetal perfusion?

110 to 160 beats/minute Explanation: A rate of 110 to 160 beats/minute in the fetal heart is appropriate for filling the heart with blood and pumping it out to the system. Faster or slower rates don't accomplish perfusion adequately

Hemoglobin

13.5 - 18.0

Cholesterol

150-200 mg/dl

Platelet count

150-450

Hemocrit

38-48

Creatine Phospbokinase (CPK) Female:

50-250 u/L

Creatine Phospbokinase (CPK) Male:

50-325 u/L

WBC (>2 yrs old)

5000-10,000/ mm3)

pH

7.35-7.45

Glucose

70-105

Calcium (Ca)

8.4-10.5

GFR < 60

= low

Arterial Blood Gas (ABG)

ABG levels are obtained to review respiratory function

A nurse places an object in the hand of a client with Alzheimer disease and asks the client to identify the object. Which term represents the client's inability to name the object?

Agnosia Explanation: Agnosia is the inability to recognize familiar objects. Aphasia is characterized by an impaired ability to speak. Apraxia refers to the client's inability to use objects properly. All three impairments usually occur in stage 3 of Alzheimer disease. Perseveration is continued repetition of a meaningless word or phrase that occurs in stage 2 of Alzheimer disease.

Which blood component is decreased in anemia?

Anemia is defined as a decreased number of erythrocytes. Leukopenia is a decreased number of leukocytes. Thrombocytopenia is a decreased number of platelets. Granulocytopenia is a decreased number of granulocytes.

Which schedule is recommended for immunization of normal infants and children in the first year of life?

Birth, 2 months, 4 months, 6 months, 12 months Explanation: The nurse needs to be aware of the schedule for immunizations as well as the latest recommendations for their use. According to the American Academy of Pediatrics (Public Health Agency of Canada), the recommended age for beginning primary immunizations of normal infants is at birth.

Creatine Kinase Isoenzymes (CK-MB)

CK-MB isoenzymes are present in the blood after a myocardial infarction. These enzymes spill into the plasma when cardiac tissue is damaged.

Which finding might be seen in a neonate suspected of having an infection?

Decreased temperature Explanation: A decreased temperature in the neonate may be a sign of infection. The neonate's color commonly changes with an infectious process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy

A nulliparous client has been in the latent phase of the first stage of labor for several hours. Despite continued uterine contractions, her cervix hasn't dilated further since the initial examination. What should the nurse observe the client for?

Exhaustion and dehydration Explanation: A client with prolonged latent stage is more likely to be exhausted and dehydrated. Chills and fever are signs of infection. Cord compression will lead to fetal distress, and meconium-stained fluid is as result of fetal distress. There is no indication of fetal distress. There is no indication of fluid overload and elevated blood pressure

A 36-year-old man who has never had mumps reports that he was just notified that an 8-year-old child of a family with whom he stayed recently has been diagnosed with mumps. Which treatment should the man receive?

Gamma globulin provides passive immunity to mumps

When developing a teaching session on glaucoma for the community, which statement would the nurse stress?

Glaucoma can be painless, and vision may be lost before the person is aware of a problem Explanation: Open-angle glaucoma causes a painless increase in intraocular pressure with loss of peripheral vision. Individuals older than age 40 should be screened. Blacks have a threefold greater chance of developing glaucoma with an increased chance of blindness than other groups. A variety of miotics and agents to decrease intraocular pressure and occasionally surgery are used to treat glaucoma.

A nurse is caring for a 4-hour-old male neonate. His heel stick hematocrit test result is 55%. Which statement is true concerning this finding?

Hematocrit of 52% to 58% is normal in a neonate because of increased blood supply during intrauterine life. Hematocrit of 55% doesn't indicate serious anemia because the value is within the normal range for a neonate. If the heel-stick blood test shows hematocrit greater than 58%, a venous blood sample is obtained for testing because hemolysis of the heel-stick sample can show a false reading. Hematocrit greater than 58% requires treatment after the physician has been notified.

According to Erikson, an adolescent who's suffering from gender identity disorder can't progress through which developmental task?

Identity versus role confusion Explanation: According to developmentalist Erik Erikson, adolescence is a time when role identity is found as a result of independence and sexual maturity; role confusion would result from the inability to integrate all experiences. Initiative versus guilt occurs when a child begins to conceptualize and interpersonalize relationships. Intimacy versus isolation occurs a stage in which the adult meets other adults and establishes relationships. Industry versus inferiority is when a child incorporates and acquires social skills.

When bathing a 1-hour-old neonate, which nursing action is most important?

Keep her under a radiant warmer, and give her a sponge bath Explanation: During the first several hours after delivery, a neonate's thermal regulatory system is adapting to extrauterine life. When bathing a neonate under a radiant warmer, the external heat decreases the chances for cold stress by decreasing the number of internal mechanisms the neonate must use to stay warm. Bathing a neonate on a table, where she's exposed to air drafts and cooler air currents, can set her up for cold stress. Bathing the neonate in a tub and then removing her increases her heat loss and metabolism. Washing only the hands and head would chill the neonate and reduce thermoregulation because most heat is lost through the head

Which term describes involuntary jerking, rhythmic movements of the eyes?

Nystagmus Explanation: Nystagmus refers to jerking movements of the eye. Oculogyric crisis involves deviation of the eyes. Exophthalmos refers to bulging eyeballs, seen in Graves disease. Diplopia means double vision.

CBC

Obtained to review blood counts

A geriatric client has experienced several adverse drug reactions. What does the nurse recognize that this client may benefit from?

Older clients commonly have diminished hepatic and renal function that reduces drug metabolism and excretion. Adverse reactions tend to be related to blood level; therefore, the client may benefit from reduced drug dosages. Adverse drug reactions aren't a cause for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the drug reacts in the client's body

A client is undergoing a diagnostic workup for suspected thyroid cancer. What is the most common form of thyroid cancer in adults?

Papillary carcinoma Explanation: Papillary carcinoma accounts for about 60% of thyroid cancer cases in adults. Follicular carcinoma accounts for roughly 20%; anaplastic carcinoma, about 15%; and medullary carcinoma, about 5%

Which symptom occurs initially in Parkinson disease?

Pill-rolling movements of the hand Explanation: Early symptoms of Parkinson disease include coarse resting tremors of the fingers and thumb. Akinesia and aspiration are late signs of Parkinson disease. Dementia occurs in only 20% of the clients with Parkinson disease.Oculogyric crisis involves deviation of the eyes. Exophthalmos refers to bulging eyeballs, seen in Graves disease. Diplopia means double vision

When counseling parents of a neonate with congenital hypothyroidism, the nurse should encourage which action?

Seek professional genetic counseling Explanation: Seeking professional genetic counseling is the best option for parents who have a neonate with a genetic disorder such as congenital hypothyroidism.

A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response?

Signs and symptoms of transition to the second stage of labor include bulging of the vaginal introitus, an increased urge to push, increased bloody show, and grunting. The client should not be assisted to the bathroom at this time as delivery is imminent.

A nurse is assessing a pregnant client. Which cardiac condition should the nurse realistically expect in a normal pregnancy?

Systolic murmur Correct Explanation: Systolic murmur is heard in up to 90% of pregnant clients, and the murmur disappears soon after the delivery. Cardiac tam-ponade, which causes effusion of fluid into the pericardial sac, isn't normal during pregnancy. Despite the increases in intravascular volume and workload of the heart associated with pregnancy, heart failure isn't normal in pregnancy. Endocarditis is most commonly associated with I.V. drug use and isn't a normal finding in pregnancy. (

The nurse is reviewing a client's prenatal history. Which finding would suggest to the nurse that it indicates a genetic risk factor?

The client has a child with cystic fibrosis. Explanation: Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age isn't a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history of preterm labor may place the client at risk for preterm labor, it doesn't correlate with genetic defects. (les

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate?

The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. Mastitis won't infect the neonate. No supplemental feedings are necessary because breast-feeding doesn't need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

Which data collection finding would the nurse identify as abnormal for a 4- month-old infant?

The spaces between the ribs (intercostal) are delineated during inspiration. Explanation: The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers; after that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute. An infant's skin can become mottled if the infant is left uncovered during the examination. (less)

A nurse is evaluating a pregnant client's fundal height. In which way should the nurse stretch the measuring tape to measure it?

To measure fundal height, the nurse should stretch a measuring tape over the client's enlarged abdomen and measure from the symphysis pubis notch to the highest level of the fundus, determined by palpation. Measuring across the abdomen and measuring from the symphysis pubis to the umbilicus are incorrect procedures for measuring fundal height. A pelvimeter is used to evaluate the size of the maternal pelvis for delivery, not fundal height.

Which noninvasive diagnostic test demonstrates the backward flow of blood through incompetent venous valves?

Venous duplex Doppler ultrasonography Explanation: Venous duplex ultrasound is a noninvasive method that visualizes veins and measures the speed, direction, and pattern of blood flow in real time. Ascending and descending venography are invasive tests of the veins that use injected contrast medium and ionizing radiation. Segmental pulse volume recordings are noninvasive tests of the peripheral arteries.

A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate?

We've found that babies can't digest solid food properly until they're 4 months old." Explanation: Infants younger than 4 months lack the enzymes needed to digest complex carbohydrates

During chemotherapy for lymphoma, a child, age 15, is at risk for stomatitis. Which statement by the child supports a nursing diagnosis of Deficient knowledge related to mouth care?

White patches on the tongue and oral mucosa indicate infection; the client should report, not remove, them. The child should use a soft toothbrush to prevent injury to the fragile oral mucosa. To prevent stomatitis, the child should rinse the mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution, and should avoid commercial mouthwashes containing alcohol, which may dry the oral mucosa.

Creatine Kinase (CK) MB band

in MI & ischemia

Complete Chemistry

is obtained to review electrolytes ( Chloride {C1-}, Bicarb (HCO-3}, Sodium {Na+} & Potassium [K+}.

Which laboratory test is used to diagnose pancreatitis

lipase is an enzyme secreted by the pancreas; when elevated, it's useful in diagnosing pancreatitis.

Creatine < 2

normal

A nurse receives a report on a client who has been diagnosed with an abdominal aortic aneurysm?(AAA). Given her knowledge of the condition, the nurse would expect the client to have which underlying disease?

therosclerosis is linked to 75% of all AAAs. Plaque damages the wall of the artery and weakens it, causing an aneurysm. Although the other conditions are related to the development of aneurysm, none is a direct cause

Which of the following immunizations should the nurse in the pediatrician's office verify the child has had on entering school? Select all that apply.

• Hepatitis B series • Diphtheria-tetanus-acelluar pertussis (DTaP) seris • Haemophilus influenzae type b series • Varicella vaccine • Inactivated polio series