NU270 Week 3 PrepU: Health, Wellness, & Illness

A nurse has just returned to her home on the East Coast of the United States after attending a nursing conference on the West Coast. Which symptoms are related to circadian rhythm and may be experienced by the nurse? Select all that apply. Insomnia Dependent edema Daytime sleepiness Decreased alertness and performance Ear pain

Insomnia Daytime sleepiness Decreased alertness and performance Explanation: The nurse may have symptoms of jet lag syndrome, which include insomnia, daytime sleepiness, and decreased alertness and performance. The other answer choices (dependent edema and ear pain) are related to cabin conditions of an airplane and usually manifest themselves sooner than symptoms of jet lag. Reference: Chapter 17: Sleep and Sleep-Wake Disorders - Page 449

Which statement best describes the pattern of maternal mortality since World War II? It has steadily decreased. It has steadily increased. After decreasing until the 1960s, it has increased steadily. It has remained constant.

It has steadily decreased. Explanation: Improved prenatal care and early ambulation after birth are factors that have decreased maternal death rates following birth over the past 70 years. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 1: Perspectives on Maternal and Child Health Care, p. 9. Chapter 1: Perspectives on Maternal and Child Health Care - Page 9

Which types of cells are supporting cells of the peripheral nervous system? Schwann cells Astrocytes Oligodendrocytes Ependymal cells

Schwann cells Explanation: The Schwann cells play an important role in supporting the peripheral nervous system. The other cells support the central nervous system. Reference: Chapter 13: Organization and Control of Neural Function - Page 308

The nurse is talking with four members of a family. Which client within the family does the nurse identify that would benefit from discussing a colonoscopy screening with their health care provider? 22-year old who experiences constipation 48-year old with regular bowel habits 47-year old whose father had polyps 18-year old who with diarrhea twice weekly

47-year old whose father had polyps Explanation: Colonoscopy screenings should begin at the age of 50 and continue every 10 years thereafter. The 47-year old with a family history of polyps should discuss a colonoscopy screening with the health care provider. Other answers are incorrect. Reference: Chapter 38: Bowel Elimination - Page 1428

The nurse is conducting a community program about removing the risk factors that may predispose clients to hypertension. Which type of prevention is the nurse focusing on? Secondary prevention Tertiary prevention Prognosis prevention Primary prevention

Primary prevention Explanation: Primary prevention is directed at keeping disease from occurring by removing all risk factors. Secondary prevention detects disease early when it is still asymptomatic and treatment measures can effect a cure or stop the disease from progressing. Tertiary prevention is directed at clinical interventions that prevent further deterioration or reduce the complications of a disease once it has been diagnosed. Reference: Chapter 1: Concepts of Health and Disease - Page 7

A client seeks care for hoarseness that has lasted for 1 month. What is the most important question for the nurse to ask when assessing the client's health history? "Do you experience frequent heartburn?" "How many alcoholic beverages do you drink each week?" "Do you smoke cigarettes, cigars, or a pipe?" "Have you strained your voice recently?"

"Do you smoke cigarettes, cigars, or a pipe?" Explanation: Persistent hoarseness may signal throat cancer. Tobacco use is the most commonly associated risk factor for throat cancer. To assess the client's risk for throat cancer, the nurse would ask about smoking habits. Although straining the voice may cause hoarseness, it would not cause hoarseness lasting for 1 month. Frequent heartburn and increased alcohol consumption are risk factors associated with throat cancer, but the most important risk factor is smoking.

The family of an older adult client is wondering why his "blood counts" are not rising after his last GI bleed. They state, "He has always bounced back after one of these episodes, but this time it isn't happening. Do you know why?" The nurse will respond based on which pathophysiologic principle? "Everything slows down when you get older. You just have to wait and see what happens." "Due to stress, the red blood cells of older adults are not replaced as promptly as younger people." "The doctor may start looking for another cause of his anemia, maybe cancer of the bone." "Don't worry about it. We can always give him more blood."

"Due to stress, the red blood cells of older adults are not replaced as promptly as younger people." Explanation: In older adults, the number of progenitor cells declines. During a stress situation such as bleeding, the red blood cells of older adults are not replaced as promptly as those of their younger counterparts. Given the scenario, the client is obviously bleeding from the GI tract. There is no reason to suspect the client has bone cancer. Telling the family "Don't worry about it" is a nontherapeutic communication technique. The nurse is trying to pacify the family and not really addressing their concern. Reference: Chapter 23: Disorders of Red Blood Cells - Page 583

A client with a foodborne illness is concerned his gastrointestinal tract will never be the same again. Which of the following would be an appropriate response from the nurse? "Give it time. Don't worry." "New gastrointestinal cells replace damaged ones constantly." "Gastrointestinal cells can adapt to the new environment created by the infection." "It's true. You may have to readjust your eating habits."

"New gastrointestinal cells replace damaged ones constantly." Explanation: Labile cells multiply constantly to replace worn-out cells. Epithelial cells of the gastrointestinal tract are labile and will constantly regenerate. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 6: Individual and Family Homeostasis, Stress, and Adaptation, p. 95. Chapter 6: Individual and Family Homeostasis, Stress, and Adaptation - Page 95

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." "OA is more common in women. RA is more common in men." "OA affects joints on both sides of the body. RA is usually unilateral." "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints."

"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally.

Two nursing students are role-playing a client assessment situation. One of the students is acting as the nurse, and the other student is acting as the client. The task is to focus on assessing the client's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask? "Where do you currently live?" "What do you usually do for fun?" "Where do your parents come from?" "Can you tell me about your childhood?"

"What do you usually do for fun?" Explanation: Assessing a client's lifestyle involves questions related to behaviors such as sleep patterns, exercise, nutrition, and recreation, as well as personal habits such as smoking and the use of illicit drugs, alcohol, and caffeine. The question about what the client does for fun reflects activities. The question about where the client lives provides information about the physical environment; the question about where the client's parents came from provides information about culture, which is also part of the environment. The question about the client's childhood provides information about the client's past life events related to health. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 5: Adult Health and Nutritional Assessment, p. 68. Chapter 5: Adult Health and Nutritional Assessment - Page 68

A client who has been confined to bed for more than 1 year is concerned about the shrinking size of his legs. How will the nurse respond to the client's concern? "Over time as one ages, cells experience dysplasia." "With decreased use of your legs, the cell size reduces." "This happens to everyone as we age." "Once atrophy occurs, there is nothing that can be done to reverse it."

"With decreased use of your legs, the cell size reduces." Explanation: Atrophy can be the consequence of decreased use, decreased blood supply, or loss of nerve supply. Disuse of a body part is often associated with the aging process and immobilization. Cell size and organ size decrease and the structures most affected are the skeletal muscles, secondary sex organs, and the heart and brain. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 6: Individual and Family Homeostasis, Stress, and Adaptation, p. 92. Chapter 6: Individual and Family Homeostasis, Stress, and Adaptation - Page 92

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client? "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By lightly pressing on the abdomen, I can check for a return of peristalsis." "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By giving you sips of water periodically, I can promote the return of peristalsis." "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By pressing on the symphysis pubis, I can check for a return of peristalsis."

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." Explanation: A postoperative client can typically have decreased or absent peristalsis because of bowel manipulation and/or administration of anesthetic agents or opioids. Auscultation of bowel sounds will help determine a return of peristalsis. Palpating the abdomen would not help with determining peristalsis return; the nurse may feel distention and firmness of the abdomen with decreased peristalsis, but this is not accurate in determining return of peristalsis. The symphysis pubis would be assessed to determine bladder fullness, not peristalsis. Giving the client sips of water would not help determine or promote the return of peristalsis; this also could be a safety issue if the client has decreased peristalsis due to emesis and subsequent potential aspiration. Reference: Chapter 30: Perioperative Nursing - Page 964

A nurse is caring for a client who is 2 days postpartum. The client asks the nurse how many hours of the day she should expect her infant to sleep. What is the most appropriate answer? 8-10 hours 10-12 hours 12-14 hours 16-20 hours

16-20 hours Explanation: Newborns (0-2 months) usually sleep approximately 16 to 20 hours per day. Reference: Chapter 17: Sleep and Sleep-Wake Disorders - Page 455

A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk? 23 31 18 28

23 Explanation: Patients with a BMI of 23 would have the lowest risk for health problems. Those with a BMI of 18 might have the increased risk associated with poor nutritional status. Those with a BMI of 28 are considered overweight, and those with a BMI of 30 to 39 are considered obese. Both of these groups have an increased risk for health problems. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 5: Adult Health and Nutritional Assessment, p. 76. Chapter 5: Adult Health and Nutritional Assessment - Page 76

Select the client at greatest risk for developing colorectal cancer. A 26-year-old male with a history of irritable bowel syndrome A 45-year-old female who takes four to six aspirin per week for arthritis A 64-year-old female whose mother had colorectal cancer A 40-year-old male with a history of peptic ulcer disease

A 64-year-old female whose mother had colorectal cancer Explanation: Colorectal cancer peaks at 60 to 70 years of age, and fewer than 20% of cases occur before age 50. Its incidence is increased among persons with a family history of cancer, persons with Crohn disease or ulcerative colitis, and those with familial adenomatous polyposis of the colon. Aspirin or other NSAIDs may protect against colorectal cancer. IBS and peptic ulcers are not risk factors. Reference: Chapter 37: Disorders of Gastrointestinal Function - Page 974

Which client would be considered to be exhibiting manifestations of "prediabetes"? A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL (10.49 mmol/L). A retired female registered nurse with a fasting plasma glucose level of 92 mg/dL (5.11 mmol/L). A school-aged child who had a blood glucose level of 115 following lunch. An older adult client who got "light-headed" when he skipped his lunch. Blood glucose level was 60 mg/dL (3.33 mmol/L) at this time.

A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL (10.49 mmol/L). Explanation: Persons with IFG (impaired fasting plasma glucose [IFG] defined by an elevated FPG of 100 to 125 mg/dL [5.55 to 6.94 mmol/L]) and/or IGT (impaired glucose tolerance [IGT] plasma glucose levels of 140 to 199 mg/dL [7.77 to 11.04 mmol/L] with an OGTT) are often referred to as having prediabetes, meaning they are at relatively high risk for the future development of diabetes as well as cardiovascular disease. Reference: Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1053

The nurse is assessing a client's risk for osteoarthritis. Which factor places the client at greatest risk for this condition? Injury Social status Age Exposure to smoke

Age Explanation: Age is the single greatest risk factor for development of osteoarthritis, in part because of the mechanical impact on joints over time. Other factors, such as obesity, injury, and heredity can also play a part, but age is the single greatest risk factor. Smoke exposure and social status are not identified risk factors for osteoarthritis. Reference: Chapter 50: Disorders of Musculoskeletal Function: Rheumatic Disorders - Page 1257

Which are characteristics of chronic conditions? (Select all that apply.) Have a rapid onset Are rarely curable Resolve spontaneously Require lifelong management Have a prolonged course

Are rarely curable Require lifelong management Have a prolonged course Explanation: Chronic conditions typically have a slower onset and prolonged course, do not resolve spontaneously, are rarely curable, and require lifelong management. Acute conditions typically have a rapid onset and short course and resolve spontaneously or are curable. Reference: Chapter 3: Health, Wellness, and Health Disparities - Page 51

Older adults with impaired cardiac function are more likely to develop which type of shock? Neurogenic shock Septic shock Anaphylactic shock Cardiogenic shock

Cardiogenic shock Explanation: Older adults, particularly those with decreased cardiac function, are prone to cardiogenic shock. Typically, underlying causes of septic shock is circulatory in nature and caused by infection, neurogenic shock occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation, and anaphylactic shock is caused by a severe allergic reaction. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2017, Chapter 14: Cardiogenic Shock

A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? Prepare for emergency cesarean birth. Change the client's position. Administer oxygen. Check for placenta previa.

Change the client's position. Explanation: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position may immediately correct the problem. An emergency cesarean birth is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Placenta previa doesn't cause variable decelerations. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression.

A nurse who works the night shift reports an inability to fall asleep at night when not on duty. This inability is related to which disruption? Diurnal rhythm Circadian rhythm Oxygen level Estrogen level

Circadian rhythm Explanation: Shift work usually creates an environment in which some circadian clock-setting cues (e.g., artificial light and rest-activity) are shifted, whereas others (e.g., natural light-dark schedule, family and social routines) are not. Reference: Chapter 17: Sleep and Sleep-Wake Disorders - Page 446

A client who has multiple sclerosis (MS) has been diagnosed with ineffective coping related to a diagnosis of chronic health alteration. What outcome is least appropriate to include in a plan of care? Communicates his feelings in a way that is comfortable. Reports feeling better about himself. Communicates a sense of helplessness to his spouse. Integrates positive self-knowledge into self-concept.

Communicates a sense of helplessness to his spouse. Explanation: All are appropriate outcomes except communicating a sense of helplessness. Some clients who are struggling with self-concept issues will communicate manipulative helplessness that encourages another (the spouse or nurse) to take charge. This does not promote coping or acceptance of self. Reference: Chapter 41: Self-Concept - Page 1644

The nurse is caring for a family and their internationally adopted child. The parents indicate the child was adopted and brought to the United States 7 days ago. What recommendation would the nurse give the family? Update the child's medical record within the next 8 weeks at their medical home. Complete a comprehensive health screening within the next week. Postpone vaccines if the child has a low-grade fever or respiratory illness. Assure the child has completed hepatitis B, C, and A screening in their home country.

Complete a comprehensive health screening within the next week. Explanation: When a child is adopted internationally, it is recommended the child have a health screening within the first few weeks of coming to the United States. The child should be screened for hepatitis after arrival to the US due to unreliable testing methods in their home country. The child's medical record should be updated with each visit. Vaccines are not postponed for mild respiratory illnesses or low-grade fevers. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 31: Health Supervision, p. 1128. Chapter 31: Health Supervision - Page 1128

The older adult client tells the nurse that she believes she is getting shorter. The nurse explains to the client that height loss is caused by which occurrence with aging? Compression of the vertebral column Reduction in muscle strength Osteoarthritis Decreased lean body mass

Compression of the vertebral column Explanation: Aging is accompanied by a progressive decline in height, especially among older women. This decline in height is attributed mainly to compression of the vertebral column and kyphosis. While the other options do occur with aging, they do not cause a decrease in height. Reference: Chapter 49: Disorders of Musculoskeletal Function: Developmental and Metabolic Disorders - Page 1232

A parent brings a 15-year-old adolescent into the clinic, stating "I cannot wake him up in the morning. He has been late for school several times and I do not know what to do any longer." Which sleep syndrome is the nurse aware is common in adolescents? Irregular sleep-wake rhythm (ISWR) Free-running sleep disorder (FRSD) Acute shifts in the sleep-wake cycle Delayed sleep phase syndrome (DSPS)

Delayed sleep phase syndrome (DSPS) Explanation: The main symptoms of DSPS are extreme difficulty falling asleep at a conventional hour of the night and awakening on time in the morning for school, work, or other responsibilities. In adults, there is evidence of association between some psychopathologic disorders and DSPS. DSPS is most common in adolescents whose frustrated parents cannot wake them up in time for school and have trouble getting them to go to bed at night. FRSD consists of a lack of synchronization between the internal sleep-wake rhythm and the external 24-hour day. ISWR is characterized by a lack of consistent pattern to the sleep-wake cycle. Reference: Chapter 17: Sleep and Sleep-Wake Disorders - Page 448 - 449

Which cardiovascular response will the nurse assess in order to determine that a client has activity intolerance? Dyspnea during activity Increased heart rate during activity Increased blood pressure during activity Increased respiratory rate during activity

Dyspnea during activity Explanation: During activity, dyspnea is not expected. If it occurs, the client should sit and rest. The other cardiovascular responses to exercise are expected: increased respiratory rate, heart rate and blood pressure. Reference: Chapter 49: Disorders of Musculoskeletal Function: Developmental and Metabolic Disorders - Page 1237

What education should the nurse give to a male client older than age 50 to help ensure early identification of prostate cancer? Perform monthly testicular self-examinations, especially after age 50. Have a transrectal ultrasound every 5 years. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly.

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Explanation: The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland because of its location in the body. A transrectal ultrasound, CBC, and BUN and creatinine levels are usually done after diagnosis to identify the extent of the disease and potential metastasis.

Which of the following sedative medications is effective in treating pruritus? Benzoyl peroxide Hydroxyzine (Atarax) Fexofenadine (Allegra) Tetracycline

Hydroxyzine (Atarax) Explanation: Atarax is a sedating medication effective in the treatment of pruritus. Benzoyl peroxide, Allegra, and tetracycline are not effective in treating pruritus. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 61: Management of Patients with Dermatologic Disorders, Pharmacologic Therapy, p. 1812. Chapter 61: Management of Patients with Dermatologic Disorders - Page 1812

A husband and wife who both have type 2 diabetes are taking part in a weight loss program. The woman asks why her husband, who has the same starting height and weight, has lost more weight than her despite identical interventions. What is the nurse's best response? Men have less water weight than women so your fat loss is similar. The number on the scale is not as important as your sense of wellness. Women's response to weight loss intervention is slower than men's. Men burn more calories than women as part of their metabolism.

Men burn more calories than women as part of their metabolism. Explanation: Women have a 5% to 10% lower basal metabolic rate than men due to a higher percentage of adipose tissue, which means men burn more calories during basic metabolic functions. Water weight is actually lower when a person has a higher percentage of fat. The client's weight loss is not simply delayed due to her gender. Telling the client not to focus on the scale does not answer her question. Reference: Chapter 39: Alterations in Nutritional Status - Page 1018

A nurse is preparing a presentation for a local community group about familial Alzheimer's disease. As part of the presentation, the nurse is planning to discuss the possible genetic basis for this condition. The nurse would describe the inheritance as which of the following? Autosomal dominant Multifactorial X-linked Autosomal recessive

Multifactorial Explanation: Familial Alzheimer's disease reflects multifactorial inheritance that involves interactions among several genes and between genes and the environment as well as the individual's lifestyle. Autosomal-dominant, autosomal-recessive, and X-linked inheritance patterns are not involved. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 8: Overview of Genetics and Genomics in Nursing, p. 127. Chapter 8: Overview of Genetics and Genomics in Nursing - Page 127

A nurse incorporates the health promotion guidelines established by the U.S. Department of Health document Healthy People 2010. Which disease/condition is a health indicator discussed in this document? Cancer Hypertension Diabetes Obesity

Obesity Explanation: The 10 leading indicators of health established by Healthy People 2010 are: physical activity, excessive weight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunizations, and access to health care. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 12. Chapter 1: Introduction to Nursing - Page 12

Which is an example of tertiary health promotion? Family counseling Pap tests Rehabilitation Water treatment

Rehabilitation Explanation: Tertiary health promotion and disease prevention begin after an illness is diagnosed and treated to reduce disability and to help rehabilitate clients to a maximum level of functioning. Therefore, rehabilitation is an example of tertiary health promotion. Family counseling and Pap tests are examples of secondary health promotion. Water treatment is an example of primary health promotion. Reference: Chapter 3: Health, Wellness, and Health Disparities - Page 56

A school nurse at an elementary school has been asked to conduct scoliosis screening for students. What will the nurse consider with the scoliosis screening request? The students are too old to screen and will no longer benefit from screening for scoliosis. The request is appropriate and the nurse can arrange to screen these students. The students are too young to screen, and the assessment should be delayed to middle school. Scoliosis screening requires sophisticated equipment and cannot be done in school.

The request is appropriate and the nurse can arrange to screen these students. Explanation: The school's request is appropriate because screening for scoliosis should begin at age 8 and be performed yearly thereafter. Also, because screening for scoliosis involves inspection of the spine and use of a scoliometer, both can be done in a school setting. Remediation:

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: stable decreased elevated within normal limits

within normal limits Explanation: A normal white blood cell count is 5,000 to 10,000 cells/mm3. Reference: Chapter 24: Asepsis and Infection Control - Page 602

A nurse working in a community clinic is discussing lifestyle modifications with a client. The client has been advised to lose weight because of a BMI greater than 25. Which statement by the nurse would be most therapeutic in helping the client? "It will be important for you to stop having between-meal snacks." "Losing weight is a challenge that I can help you with." "I can offer you some information outlining a variety of ways to lose weight." "There are herbal preparations for weight loss that are very effective."

"I can offer you some information outlining a variety of ways to lose weight." Explanation: The therapeutic response would put the client in a position to make an individual choice. The nurse would offer options to allow for choice. Telling the client that losing weight is a challenge the nurse can help with puts the focus on the nurse and does not offer options. Many weight loss plans include meals plus snacks as well as limiting options. Offering herbal preparation also limits the options given to the client.

The adult child of a client with end-stage Alzheimer disease asks the nurse if Alzheimer disease can be passed on to him or her. What is the nurse's most accurate response? "Research supports that the disease is always inherited." "Research supports that late onset is genetic." "There is no evidence that the disease is genetic." "Research supports a possible genetic link with an early onset."

"Research supports a possible genetic link with an early onset." Explanation: Alzheimer disease can be caused by a number of factors, and each case is unique to that individual. There is research that has identified genes that predispose a person to the development of early-onset Alzheimer disease. Reference: Chapter 16: Disorders of Brain Function - Page 472

The nurse is providing education about the nutrient content of the Therapeutic Lifestyle Changes (TLC) diet to a community group. What information will the nurse provide? Select all that apply. Protein should make up approximately 15% of total calories. Total fat should make up only 5% of the total calories. Dietary fiber should be 20 to 30 grams per day. Cholesterol should be less than 1 gram per day. Carbohydrates should make up 50% to 60% of the total calories.

Carbohydrates should make up 50% to 60% of the total calories. Dietary fiber should be 20 to 30 grams per day. Protein should make up approximately 15% of total calories. Explanation: According to the nutrient content of the TLC diet, cholesterol should make up less than 200 mg/day, carbohydrates should make up 50% to 60% of the total calories, dietary fiber should be 20 to 30 grams per day, protein should make approximately 15% of the total calories, and fat should make up 25% to 30% of the total calories. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 27: Management of Patients With Coronary Vascular Disorders, Dietary Measures, p. 754. Chapter 27: Management of Patients With Coronary Vascular Disorders - Page 754

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? Classes at community centers to teach about smoking cessation strategies Legislation that requires homes and apartments be checked for asbestos leakage Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays

Classes at community centers to teach about smoking cessation strategies Explanation: Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 23: Management of Patients With Chest and Lower Respiratory Tract Disorders, p. 620. Chapter 23: Management of Patients With Chest and Lower Respiratory Tract Disorders - Page 620

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply. Increased gag reflex Increased systolic and diastolic blood pressure Decreased facial hair Decreased near vision Increased mental confusion Decreased tissue elasticity

Decreased near vision Increased systolic and diastolic blood pressure Decreased tissue elasticity Explanation: Decreased near vision (presbyopia), increased systolic and diastolic blood pressure, and decreased tissue elasticity are normal signs of aging. Decreased facial hair, increased gag reflex, and increased mental confusion are not normal signs of aging.

What is the best nursing intervention to promote health in a client at risk for heart disease? Instructing the client to adhere to a high-sodium diet Taking the client's pulse rate daily Informing the client that the client must lose weight Emphasizing a client's strengths to encourage weight loss

Emphasizing a client's strengths to encourage weight loss Explanation: Nurses promote health by identifying, analyzing, and maximizing each client's own individual strengths as components of preventing illness, restoring health, and facilitating coping with disability or death. Emphasizing the client's strengths to encourage weight loss is the most effective way to promote this client's health. Informing the client that the client must lose weight would not help the client use his or her strengths to accomplish the goal. Low-sodium diets can prevent heart disease. Taking the pulse daily would not prevent heart disease. Reference: Chapter 1: Introduction to Nursing - Page 11-12

A nurse is working with a couple who will be undergoing genetic testing. Which of the following would the nurse prepare the couple for as the first genetic test? Carrier testing DNA analysis Chromosomal analysis Family history

Family history Explanation: The family history is considered the first genetic test. Other additional testing methods that follow include chromosomal and DNA analyses and carrier testing. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 8: Overview of Genetics and Genomics in Nursing, p. 132. Chapter 8: Overview of Genetics and Genomics in Nursing - Page 132

The National Center for Health Statistics uses data from healthcare agencies to issue quarterly and annual reports on performance related to goals for improving the health of the U.S. population. Which initiative is targeted with improving the health of all Americans? Healthy People 2030 Quality Indicators Agency for Healthcare Research and Quality The Joint Commission

Healthy People 2030 Explanation: The Healthy People 2030 campaign provides an overall action plan to improve the health and quality of life of people living in the United States. The initiative includes leading health indicators for measuring the overall health of the U.S. population. The Joint Commission is an independent agency that accredits and certifies healthcare organizations and programs in the United States. The AHRQ is the organization that developed standardized quality indicators used to measure healthcare quality at the federal, state, and local levels. Quality indicators are not an initiative; they are standards for measuring healthcare quality. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice, p. 7. Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice - Page 7

A 62-year-old man who is overweight has just been diagnosed with type 2 diabetes. The nurse educator is instructing him in the ways his diabetes can be controlled. The nurse should initially prioritize which action? Teaching the client about the action and safe administration of insulin. Helping the client make meaningful changes to his diet and activity level. Assisting the client with the appropriate choice of oral antihyperglycemics. Educating the client about the risks and management of hypoglycemia.

Helping the client make meaningful changes to his diet and activity level. Explanation: Weight loss and dietary management are the initial focus of treatment for type 2 diabetes. For many people with type 2 diabetes, the benefits of exercise include a decrease in body fat, better weight control, and improvement in insulin sensitivity. If good glycemic control cannot be achieved with exercise and diet, then antidiabetic agents and even insulin can be added to the treatment plan. Education is imperative, but there is no need to emphasize hypoglycemia, since there is no evidence the client is on a medication that would cause hypoglycemia. Reference: Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1079

The nurse is caring for a client with diabetes. Which of these findings is cause for concern, leading the nurse to initiate client education? The client is dependent on insulin. The client states insulin is produced in the pancreas. Glucose level is 80 mg/dL (4.44 mmol/L). Hemoglobin A1C level is 8.7%.

Hemoglobin A1C level is 8.7%. Explanation: Glycated hemoglobin test (hemoglobin A1c) should be 6% to 7% in clients with diabetes. Maintaining the desired level reduces complications of diabetes. Reference: Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1075

After completing a history and physical assessment of a client who has just found out that she is pregnant, the nurse determines the need for a referral for a genetic evaluation based on which of the following? Select all that apply. Brother with intellectual disability Age of 30 at expected time of delivery Negative alpha-fetoprotein screening Two previous unexplained miscarriages History of diabetes

History of diabetes Brother with intellectual disability Two previous unexplained miscarriages Explanation: Indicators that suggest the need for a genetics referral include maternal age of 35 years or more at expected time of delivery, history of diabetes, family history of intellectual disability, positive alpha-fetoprotein screening test, and two or more unexplained miscarriages. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 8: Overview of Genetics and Genomics in Nursing, p. 132. Chapter 8: Overview of Genetics and Genomics in Nursing - Page 132

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage? Hypothalamus Midbrain Cerebral cortex Medulla

Hypothalamus Explanation: The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods. The medulla and midbrain are part of the reticular activating system (RAS), which plays a part in the cyclic nature of sleep. The cerebral cortex does not have any role in the sleep process. Reference: Chapter 34: Rest and Sleep - Page 1201

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage? Medulla Midbrain Cerebral cortex Hypothalamus

Hypothalamus Explanation: The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods. The medulla and midbrain are part of the reticular activating system (RAS), which plays a part in the cyclic nature of sleep. The cerebral cortex does not have any role in the sleep process. Reference: Chapter 34: Rest and Sleep - Page 1201

The nurse is teaching a new mother about caring for her baby and reducing the risk for infection. On what principle does the nurse base the knowledge of passive immunity? Infants are protected at birth from infection by maternal IgM. Infants are protected at birth from infection by maternal IgA. Infants are protected at birth from infection by maternal IgG. Infants are protected at birth from infection by maternal IgD.

Infants are protected at birth from infection by maternal IgG. Explanation: At birth, infants are protected from infection my maternal IgG antibodies that have crossed the placenta during fetal development. Infants are normally deficient in IgA, IgM, IgD, and IgE because immunoglobulins do not normally cross the placenta. Reference: Chapter 12: Disorders of the Immune Response - Page 298

The student attends a health fair and has his serum cholesterol checked. He has a high lipoprotein level (LDL). He understands which of the following about LDL cholesterol? It is associated with a low intake of saturated fats. It is believed to play an active role in the pathogenesis of the atherosclerotic lesion. It transports cholesterol away from cells to the liver for excretion. It has a low cholesterol content.

It is believed to play an active role in the pathogenesis of the atherosclerotic lesion. Explanation: Hyperlipidemia, particularly LDL, with its high cholesterol content, is also believed to play an active role in the pathogenesis of the atherosclerotic lesion. Dietary cholesterol tends to increase LDL cholesterol. HDL participates in the reverse transport of cholesterol by carrying cholesterol from the peripheral tissues back to the liver. Reference: Chapter 26: Disorders of Blood Flow and Blood Pressure Regulation - Page 642

Which statement best explains the action of the lactational amenorrhea method (LAM) of fertility control? LAM prevents introduction of sperm into the vagina. LAM thickens the cervical mucus and blocks sperm. LAM causes suppression of the ovulation process. LAM prevents fertilization between the egg and sperm.

LAM causes suppression of the ovulation process. Explanation: LAM prevents pregnancy by suppressing the ovulation process. Withdrawal and barrier methods of contraception prevent the introduction of sperm into the vagina. The copper IUD, combined hormonal methods, and oral contraceptive pills (OCPs) prevent fertilization between the egg and the sperm. Levonorgestrel system thickens the cervical mucus and blocks sperm. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 4: Common Reproductive Issues, p. 142. Chapter 4: Common Reproductive Issues - Page 142

A 66-year-old African-American client has recently visited a physician to confirm a diagnosis of gastric cancer. The client has a history of tobacco use and was diagnosed 10 years ago with pernicious anemia. He and his family are shocked about the possibility of cancer because he was asymptomatic prior to recent complaints of pain and multiple gastrointestinal symptoms. On the basis of knowledge of disease progression, the nurse assumes that organs adjacent to the stomach are also affected. Which of the following organs may be affected? Choose all that apply. Lungs Liver Bladder Pancreas Duodenum

Liver Pancreas Duodenum Explanation: Most gastric cancers are adenocarcinomas; they can occur anywhere in the stomach. The tumor infiltrates the surrounding mucosa, penetrating the wall of the stomach and adjacent organs and structures. The liver, pancreas, esophagus, and duodenum are often already affected at the time of diagnosis. Metastasis through lymph to the peritoneal cavity occurs later in the disease. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 46: Management of Patients With Gastric and Duodenal Disorders, Pathophysiology, p. 1304. Chapter 46: Management of Patients With Gastric and Duodenal Disorders - Page 1304

An obstetrics nurse is counseling an expectant mother. The mother is concerned about letting people hold her baby once the baby is born, fearing that the infant will get sick. What should the nurse explain to the mother? The innate immune system will protect the baby. IgA that is present at birth, and which originates with the mother, will protect the baby, Maternal immunoglobulins cross the placenta and protect the newborn early in life. Abundant lymphoid tissues protect the infant in the first few months of life

Maternal immunoglobulins cross the placenta and protect the newborn early in life. Explanation: Passive immunity is immunity transferred from another source. An infant receives passive immunity naturally from the transfer of antibodies from its mother in utero and through breast milk. Maternal IgG crosses the placenta and protects the newborn during the first few months of life. Innate immunity are not effective yet, and protection is unrelated to the amount of lymphoid tissue. Reference: Chapter 11: Innate and Adaptive Immunity - Page 261

The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase? Select all that apply. Decrease the need for exogenous insulin Help reduce cholesterol levels May reduce postprandial glucose levels May improve blood glucose levels Increase potassium levels

May improve blood glucose levels Decrease the need for exogenous insulin Help reduce cholesterol levels Explanation: Increased fiber in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood (ADA, 2008b; Geil, 2008). Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 51: Assessment and Management of Patients With Diabetes, Fiber, p. 1463. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1463

Which of the following is accurate regarding wellness? Select all that apply. It is a specific health status with the absence of disease. One tries to maximize one's own health. It requires a conscious commitment. It is the result of adopting lifestyle behaviors for the attainment of one's highest potential. Is the same for every person.

One tries to maximize one's own health. It requires a conscious commitment. It is the result of adopting lifestyle behaviors for the attainment of one's highest potential. Explanation: Wellness, as a reflection of health, involves a conscious and deliberate attempt to maximize one's health. Wellness requires planning and conscious commitment and is the result of adopting lifestyle behaviors for the purpose of attaining one's highest potential for well-being. Wellness is not the same for every person. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 4: Health Education and Health Promotion, p. 55. Chapter 4: Health Education and Health Promotion - Page 55

A 59-year-old African American man has opted for hormonal androgen deprivation therapy (ADT) to treat his prostate cancer. Which surgical procedures is the client most likely to undergo? Orchiectomy Vasectomy Hydrocelectomy Circumcision

Orchiectomy Explanation: ADT is commonly used to suppress androgenic stimuli to the prostate by decreasing the level of circulating plasma testosterone or interrupting the conversion to or binding of dihydrotestosterone (DHT). As a result, the prostatic epithelium atrophies (decreases in size). This effect is accomplished by an orchiectomy (removal of the testes). Circumcision is excision of the foreskin, or prepuce, of the glans penis. Vasectomy is the ligation and transection of part of the vas deferens to prevent the passage of the sperm from the testes. Hydrocelectomy describes the surgical repair of a hydrocele, a collection of fluid in the tunica vaginalis. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, p. 1770. Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders - Page 1770

During a class, a student asks the instructor, "I read something that said that in some conditions, the presence of a gene mutation may not actually lead the person to actually show the trait. How can this be?" The instructor interprets the student's statement as reflecting which of the following? Translocation Variable expression Penetrance Deletion

Penetrance Explanation: Penetrance refers to the percentage of people known to have a particular gene mutation and who actually show the trait. In some conditions, a gene mutation does not invariably mean that a person has or will develop an autosomal-inherited condition. Deletion refers to a genetic mutation involving the loss of a gene. Translocation refers to a genetic mutation involving a rearrangement of genes. Variable expression is the variation in the degree to which a trait is manifested. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 8: Overview of Genetics and Genomics in Nursing, p. 120. Chapter 8: Overview of Genetics and Genomics in Nursing - Page 120

According to Maslow, which category of needs represents the most basic on the hierarchy? Safety and security Physiologic needs Self-actualization Sense of belonging

Physiologic needs Explanation: Physiologic needs must be met before an individual is able to move toward psychological health and well-being. Self-actualization is the highest level of need. Safety and security, while a lower level of need, are not essential to physiologic survival. A sense of belonging and affection needs are not essential to physiologic survival. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice, p. 5. Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice - Page 5

Which of the following is the most successful treatment for gastric cancer? Removal of the tumor Radiation Palliation Chemotherapy

Removal of the tumor Explanation: There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 46: Management of Patients With Gastric and Duodenal Disorders, Medical Management, p. 1304. Chapter 46: Management of Patients With Gastric and Duodenal Disorders - Page 1304

A baby is born with what the primary care provider believes is a diagnosis of trisomy 21. This means that the infant has three number 21 chromosomes. What factor describes this genetic change? The mother also has genetic mutation of chromosome 21. During meiosis, a reduction of chromosomes resulted in 23. The client will have a single X chromosome and infertility. The client has a nondisjunction occurring during meiosis.

The client has a nondisjunction occurring during meiosis. Explanation: During meiosis, a pair of chromosomes may fail to separate completely, creating a sperm or oocyte that contains either two copies or no copy of a particular chromosome. This sporadic event, called nondisjunction, can lead to trisomy. Down syndrome is an example of trisomy. The mother does not have a mutation of chromosome 21, which is indicated in the question. Also, trisomy does not produce a single X chromosome and infertility. Genes are packaged and arranged in a linear order within chromosomes, which are located in the cell nucleus. In humans, 46 chromosomes occur in pairs in all body cells except oocytes and sperm, which contain only 23 chromosomes. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 10: Fetal Development and Genetics, p. 353. Chapter 10: Fetal Development and Genetics - Page 353

The client is ambulating in the room and walks around a bedside table. What is the bestexplanation for why the client does not bump into the table? The brain is sending impulses to the muscles to avoid the table. The client's muscles are being stretched to walk around the table. The cerebellum is responding to impulses from the inner ear. The client is aware of spatial relationships to avoid the table.

The client is aware of spatial relationships to avoid the table. Explanation: The client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine sense relates to the sensory organs in the inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space. When the extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture (e.g., when the knee buckles under, the reflex contraction aids the person to straighten the knee). This does not contribute to perception of where objects are in space. Reference: Chapter 33: Activity - Page 1135

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? The client has a daily fluid intake of 2,000 to 3,000 ml. The client returned from a foreign country 2 days ago. The client repeatedly ignores the urge to defecate. The client consumes large quantities of fresh vegetables.

The client returned from a foreign country 2 days ago. Explanation: Eating native food and drinking water in a foreign country may cause problems with digestion and elimination, such as diarrhea. To promote normal bowel elimination, people should drink 2,000 to 3,000 ml of fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation. Reference: Chapter 38: Bowel Elimination - Page 1422

The nurse is providing education to a client with Addison disease who has been treated for hyponatremia and hypoglycemia related to the disease. The nurse inform the client that which action should be taken to ensure control of these conditions? The client should be sure to decrease carbohydrate and fat intake. The client should be sure to take an extra dose of his medication if he begins to feel weak or confused. The client should eat and exercise on a regular schedule. The client should limit salt intake.

The client should eat and exercise on a regular schedule. Explanation: Because people with Addison disease are likely to have episodes of hyponatremia and hypoglycemia, they need to have a regular schedule for meals and exercise. It is not necessary to limit carbohydrate and fat intake or salt related to this disorder. Reference: Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1066

The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education? The client will have restoration of breast function. The client will demonstrate improved coping skills. The client will demonstrate self-efficacy and improved body image. The client will be able to perform proper breast self-examination for breast cancer detection and prevention.

The client will be able to perform proper breast self-examination for breast cancer detection and prevention. Explanation: This client education is focused on teaching the client a psychomotor skill for the purpose of early detection of breast cancer. Therefore, an appropriate learning outcome would be that the client is able to perform the skill properly. This client does not have any self-image problems, breast dysfunction, or poor coping skills, so outcomes related to these issues would not be appropriate. Reference: Chapter 9: Teaching and Counseling - Page 186

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of the fetus. The client's BPP score is 8. What does this score indicate? The client should repeat the test in 1 week. The fetus isn't in distress at this time. The fetus should be delivered within 24 hours. The client should repeat the test in 24 hours.

The fetus isn't in distress at this time. Explanation: The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may be repeated if the score isn't within normal limits.

The nurse is assessing a 9-year-old boy with pneumonia. Which finding is a factor for this child's morbidity? Child's height and weight plot at the 50th percentile on the growth chart. Child's white blood cell (WBC) count is within normal limits. Medical records reveal a history of asthma. Child is active in a Boy Scout troop.

The nurse is assessing a 9-year-old boy with pneumonia. Which finding is a factor for this child's morbidity? You Selected: Medical records reveal a history of asthma. Correct response: Medical records reveal a history of asthma. Explanation: Asthma is a morbidity factor for additional childhood illness, particularly respiratory illness. The child's height and weight are appropriate and not associated with increased risk. The normal WBC count may help to determine if the pneumonia is bacterial or viral. Being in a Boy Scout troop may increase the risk of exposure, but would not be as closely associated with morbidity as is asthma. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 1: Perspectives on Maternal and Child Health Care, p. 15. Chapter 1: Perspectives on Maternal and Child Health Care - Page 15

The number of people with disabilities is expected to increase over time. What is a major contributor to this prediction? The ability to cure chronic disorders that are acquired The survival of people with severe trauma, chronic disorders, and early-onset disabilities The decrease in risk factors for early-onset disabilities that are genetic in cause The decrease in the number of people with early-onset disabilities

The survival of people with severe trauma, chronic disorders, and early-onset disabilities Explanation: The number of people with disabilities is expected to increase over time as people with early-onset disabilities, chronic disorders, and severe trauma survive and have normal or near-normal lifespans. There has not been a decrease in the number of people with early-onset disabilities. Acquired chronic disorders still cannot be cured. Genetic risk factors for early-onset disabilities have not decreased. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 9: Chronic Illness and Disability, p. 150. Chapter 9: Chronic Illness and Disability - Page 150

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? They are medium-pitched blowing sounds heard over the major bronchi. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. They are low-pitched, soft sounds heard over peripheral lung fields. They are loud, high-pitched sounds heard primarily over the trachea and larynx.

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds. Reference: Chapter 39: Oxygenation and Perfusion - Page 1494

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? Vesicular Bronchovesicular Crackles Bronchial

Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx. Reference: Chapter 39: Oxygenation and Perfusion - Page 1494

An older adult client has recently been diagnosed with rheumatoid arthritis. The nurse should focus assessment on which aspects? Weight and nutritional status Oxygenation and respiratory status Cognition and coping skills Sodium and potassium levels

Weight and nutritional status Explanation: Anorexia is a common extra-articular symptom of rheumatoid arthritis. Consequently, there is a need to monitor the client's nutritional status and intake. Cognition, respiratory status, and electrolytes are not typically affected. Reference: Chapter 49: Disorders of Musculoskeletal Function: Developmental and Metabolic Disorders - Page 1264

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a large wound with considerable tissue loss allowed to heal naturally a surgical incision with sutured approximated edges a wound healing naturally that becomes infected. a wound left open for several days to allow edema to subside

a surgical incision with sutured approximated edges Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed. Reference: Chapter 32: Skin Integrity and Wound Care - Page 1048

A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. The client tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: hemolysis of fetal red blood cells (RBCs). an unknown cause. a neurologic disorder. inadequate nutrition.

an unknown cause. Explanation: The cause of hyperemesis gravidarum isn't known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.

A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? presence of menses breast sensitivity uterine enlargement fetal heart tones

breast sensitivity Explanation: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea, not the presence of menses, is expected during this time. Uterine enlargement and fetal heart tones don't occur until after the first 4 weeks of pregnancy.

A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? checking for the umbilical cord around the neonate's neck turning the neonate's head to the side to drain secretions placing antibiotic ointment in the neonate's eyes assessing the neonate for respirations

checking for the umbilical cord around the neonate's neck Explanation: After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment is administered to the neonate after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The neonate's head isn't turned during delivery. After birth, the neonate is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after birth.

A client with Crohn's disease in remission is admitted to the nursing unit for follow-up care. The remission state is characterized by: permanent relief from the signs and symptoms. disappearance of signs and symptoms associated with the disease. periodic occurrence in clients with long-standing diseases. reactivation of the disease and presence of symptoms.

disappearance of signs and symptoms associated with the disease. Explanation: Remission is a temporary state of disappearance of the signs and symptoms related to a particular disease. It is of short duration, but the duration is unpredictable. It is a condition opposite to exacerbation, which is characterized by reactivation of symptoms. Remission is not permanent, but is rather a temporary relief from signs and symptoms. Exacerbation is the periodic occurrence of disease in clients with chronic diseases. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 3: Health, Illness and Disparities, p. 46. Chapter 3: Health, Wellness, and Health Disparities - Page 46

A nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: have a mammogram annually. have a hormonal receptor assay annually. have a physician conduct a clinical examination every 2 years. perform breast self-examination annually.

have a mammogram annually. Explanation: The American Cancer Society guidelines state that women age 40 and older should have a mammogram annually and a clinical examination at least annually (not every 2 years). All women should perform breast self-examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, Mammography, p. 1725. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1725

The nurse is teaching a postmenopausal client about strategies to prevent the development of osteoporosis. On which topic should the nurse focus as primary prevention for the disorder? taking regular estrogen replacement therapy participating in cardiovascular exercises regularly maintaining a body mass index of less than 20 increasing calcium and vitamin D in the diet

increasing calcium and vitamin D in the diet Explanation: Primary prevention of osteoporosis includes maintaining optimal calcium and vitamin D intake. Although estrogen replacement can reduce the risk for osteoporosis, it can increase the risk for certain cancers and should therefore not be recommended as first-line prevention. Cardiovascular exercise will directly help in the prevention of osteoporosis only if it involves weight-bearing activity, such as walking or jogging. A lower body mass index (weight under 125 pounds for women of average height) is a risk factor for developing osteoporosis rather than preventing it.

Parents tell the nurse their 3-year-old refuses to eat meat but are pleased she drinks "lots of milk." What risk does the nurse identify? dental caries iron deficiency obesity interference with growth

iron deficiency Explanation: Meat is an important iron source while calcium in milk consumed in large quantities can block iron absorption. Alternate protein sources can replace the meat in the child's diet for growth. Excess milk intake that boosts calories consumed can be an obesity-causing factor. Lactose from milk in constant contact with the teeth can promote development of dental caries. However, these risks are slight, with the iron deficiency risk pronounced. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 27: Growth and Development of the Preschooler, p. 1036. Chapter 27: Growth and Development of the Preschooler - Page 1036

A pregnant client with diabetes mellitus is at risk for having a large-for-gestational-age neonate because: excess insulin reduces placental functioning. the mother follows a high-calorie diet. excess sugar causes reduced placental functioning. insulin acts as a growth hormone on the fetus.

nsulin acts as a growth hormone on the fetus. Explanation: Insulin acts as a growth hormone on the fetus. Therefore, pregnant clients with diabetes must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean birth. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.

A client is in the manic phase of bipolar disorder. To help the client maintain adequate nutrition, the nurse should plan to: provide large, attractive meals. provide a stimulating mealtime environment. offer finger foods and sandwiches. let the client choose some favorite foods.

offer finger foods and sandwiches. Explanation: Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't sit still for large meals. Providing a stimulating mealtime environment is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Letting the client choose some favorite foods is inappropriate because the client has a short attention span and has trouble making choices.

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of: drinking and smoking habits of the client. social and emotional setting of the client. physiologic or lifestyle changes in the client. nature and amount of food eaten by the client.

physiologic or lifestyle changes in the client. Explanation: Fecal incontinence mainly results from physiologic or lifestyle changes that impair muscle activity and sensation of the gastrointestinal tract. Particularly in the older adult, the weakening of the intestinal walls and decreased muscle tone can lead to bowel incontinence. Reference: Chapter 38: Bowel Elimination - Page 1421

The nurse is performing her morning assessment on a 69-year-old client on a medical-surgical unit. Upon assessing her pupils the nurse notices that they are equal and responsive to light but not to accommodation. The nurse is aware that with aging the lens becomes thicker and its capsule less elastic so she believes this to be the case. When accommodation is diminished in an older person as a result of aging this is referred to as: myopia. presbyopia. farsightedness. hyperopia.

presbyopia. Explanation: The term presbyopia refers to a decrease in accommodation that occurs because of aging. Hyperopia is the same as farsightedness and myopia refers to nearsightedness (when the person can see close objects without problems but distant objects are blurred). Reference: Chapter 20: Disorders of Hearing and Vestibular Function - Page 494

A nurse has recently completed the administration of seasonal influenza vaccinations for the residents of a long-term care facility. Which aim of nursing has the nurse most clearly demonstrated? facilitating coping restoring health preventing illness promoting health

preventing illness Explanation: Vaccinations are one of the most concrete measures that nurses take to prevent illness in clients, as the antibody production that is induced by vaccination actively prevents the recipient from developing the influenza. Promoting health includes preventing illness but also other concepts, such as optimizing health and well-being, and thus is not as accurate in this case as preventing illness. Restoring health is a return to a normal or healthy condition such as an acute illness. Coping is to face and deal with responsibilities, problems, or difficulties, especially successfully or in a calm or adequate manner. Reference: Chapter 1: Introduction to Nursing - Page 11-12

A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review? increasing homocysteine levels, reducing weight, and a sedentary lifestyle reducing the intake of calcium and increasing the intake of sodium, and incorporating rest periods reducing cholesterol levels, increasing activity levels progressively, and coping strategies reducing the intake of unsaturated fats, participating regularly in anaerobic burst training activity, and increasing fluid intake

reducing cholesterol levels, increasing activity levels progressively, and coping strategies Explanation: Cardiac rehabilitation is designed to assist the client in regaining functioning gradually. It also includes heart-healthy information such as dietary changes, a progressive increase in activity, and effective coping strategies for stress reduction. The emphasis is on lifestyle changes and reducing the risk of recurrence. The information related to unsaturated fats and participation in burst training is inaccurate. There is no need to reduce calcium intake and sodium is not increased. Homocysteine levels should be decreased, not increased.

A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review? reducing cholesterol levels, increasing activity levels progressively, and coping strategies reducing the intake of calcium and increasing the intake of sodium, and incorporating rest periods increasing homocysteine levels, reducing weight, and a sedentary lifestyle reducing the intake of unsaturated fats, participating regularly in anaerobic burst training activity, and increasing fluid intake

reducing cholesterol levels, increasing activity levels progressively, and coping strategies Explanation: Cardiac rehabilitation is designed to assist the client in regaining functioning gradually. It also includes heart-healthy information such as dietary changes, a progressive increase in activity, and effective coping strategies for stress reduction. The emphasis is on lifestyle changes and reducing the risk of recurrence. The information related to unsaturated fats and participation in burst training is inaccurate. There is no need to reduce calcium intake and sodium is not increased. Homocysteine levels should be decreased, not increased.

Which behaviors represent effective coping mechanisms? Select all that apply. denying responsibility for a DUI conviction learning relaxation techniques sleeping 14 hours a night setting limits with family members who upset you sleeping 3 hours a night taking a vacation

setting limits with family members who upset you learning relaxation techniques taking a vacation Explanation: Coping mechanisms can have positive or negative effects on a client's well-being. All of these examples represent coping, either effective or ineffective. Reference: Chapter 42: Stress and Adaptation - Page 1670

An overweight adolescent client has lost 12 lb (5.4 kg) in 8 weeks using diet strategies. The client reaches a weight loss plateau and is discouraged. The nurse instructs the client to keep a food diary for what purpose? to provide a written record of caloric intake for the nurse to help the client analyze how much food is consumed and when to help the nurse determine whether the diet is being followed to help the client stay busy and more focused on losing weight

to help the client analyze how much food is consumed and when Explanation: Keeping a food diary allows the adolescent client to use the cognitive level of formal operations to help identify and evaluate eating behaviors of which he may not be aware. It is primarily a tool to assist in self-correction and behavior modification. The client does not need to be preoccupied with weight loss. The nurse can provide insights based on the diary entries, but this device is not for the nurse.