Chapters 21-30

Chapter 22 1. A nurse is talking with the father of a 12-year-old boy who is concerned that he hasn't observed any indications that his son is approaching puberty. The nurse should explain that the first sign of sexual maturation in boys is A. the appearance of downy hair on the upper lip. B. hair growth in the axillae. C. enlargement of the testes and the scrotum. D. deepening of the voice.

1. A. INCORRECT: Emerging facial hair is a later pubescent change. B. INCORRECT: Hair growth in nongenital areas is a later pubescent change. C. CORRECT: The first prepubescent change in boys is an increase in the size of the testicles along with a thinning and expanding of the scrotum. D. INCORRECT: Changing vocal quality is a later pubescent change.

Chapter 23 1. A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "If I am having any discomfort, I'll just go to an urgent care center." D. "If I am feeling stressed, I will remind myself that this is something I should expect."

1. A. INCORRECT: For protection against a wide variety of communicable illnesses, adults should obtain the immunizations the CDC recommends throughout the lifespan, not just during childhood. B. CORRECT: Young adulthood is a time of relative health, but routine screenings and health care visits are still important. C. INCORRECT: Urgent care centers offer limited services, typically for acute injuries or problems that cannot wait until a primary care provider is available. Young adults should establish a relationship with a primary care provider to consult for nonurgent health problems. D. INCORRECT: Although it is true that stress is inevitable, chronic stress can lead to severe health alterations. Young adults who have stress that is recurrent or escalating should seek medical care.

CHAPTER 25 1. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority for further assessment and intervention? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my son to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I'm struggling with helping out in my community. I just don't know what I can do."

1. A. INCORRECT: It is common for older adults, who are in the stage Erikson describes as integrity vs. despair, to face the challenges of retirement, such as less income and the loss of a work role. This problem is not the priority for assessment and intervention. B. INCORRECT: It is common for older adults, who are in the stage Erikson describes as integrity vs. despair, to face the challenge of changes in family structure, such as role reversal. This problem is not the priority for assessment and intervention. C. INCORRECT: It is common for older adults, who are in the stage Erikson describes as integrity vs. despair, to face the challenge of coping with multiple losses, such as the death of friends. This problem is not the priority for assessment and intervention. D. CORRECT: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of middle adulthood to develop generativity (such as by reaching and helping in the community) vs. self‐absorption and stagnation. This older adult is still struggling with this task and needs assistance in working through that dilemma.

Chapter 26 1. A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and her last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.

1. A. INCORRECT: The nurse should ask the client what she wants the nurse to call her. B. CoRRECT: Open-ended questions help the client tell her story in her own way. Closed-ended questions are useful for clarifying and verifying information the nurse gathers from the client's story. C. CoRRECT: A quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview. D. INCORRECT: Having the client fill out a printed history form might deter the establishment of a therapeutic relationship. When the nurse asks about her history, the client might feel they are wasting time because she already wrote that information on the form. E. CORRECT: The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the assessment, such as the examination.

Chapter 24 1. A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of accomplishing Erikson's tasks for psychosocial development during middle adulthood? A. The client evaluates his behavior after a social interaction. B. The client states he is learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation.

1. A. INCORRECT: This is a task middle adults should have accomplished to master an earlier developmental stage. B. INCORRECT: This is a task middle adults should have accomplished to master an earlier developmental stage. C. INCORRECT: This is a task middle adults should have accomplished to master an earlier developmental stage. D. CoRRECT: The task for a middle adult is generativity vs. stagnation. Concern for the next generation is a positive sign that the middle adult is meeting the task.

1. A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill in 2 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the face

1. A. CoRRECT: Capillary refill in less than 2 seconds is an expected finding. B. INCORRECT: Pitting edema is an unexpected finding that reflects excess fluid that has accumulated in body tissues. C. INCORRECT: Pallor in the nail beds is an unexpected finding that reflects anemia or impaired circulation. D. CoRRECT: Thicker skin on the palms of the hands and the soles of the feet is an expected finding. E. CoRRECT: Light brown macules on the face are likely to be freckles, which are an expected finding.

1. A nurse in a provider's office is preparing to perform a breast examination for an older adult who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

1. A. CoRRECT: In older adulthood, the nipples become smaller and flatter. B. INCORRECT: Older adults have more adipose tissue and less glandular tissue in their breasts. C. INCORRECT: Older adults have no nipple discharge, unless there is some underlying pathophysiology. D. CoRRECT: In older adulthood, the breasts become softer and more pendulous. E. CoRRECT: Nipple inversion is common among older adults, due to fibrotic changes and shrinkage.

CHAPTER 28 1. A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B."Tell me what you can taste." C."Clench your teeth." D."Raise your eyebrows." E."Tell me when you feel a touch."

1. A. CoRRECT: Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when he feels a gentle touch on his face from a wisp of cotton. B. INCORRECT:TestingcranialnerveVII,thefacialnerve,involvestestingthemouthfortastesensations. C. CoRRECT: Testing cranial nerve V, the trigeminal nerve, involves testing the strength of muscle contraction by asking the client to clench his teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint. D. INCORRECT: Testing cranial nerve VII, the facial nerve, involves testing for a range of facial expressions by having the client smile, raise his eyebrows, puff out his cheeks, and perform other facial movements. E. CoRRECT: The first step of testing cranial nerve V, the trigeminal nerve, is to have the client close his eyes.

CHAPTER 27 1. A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3° C (101° F), a pulse rate of 114/min, and a respiratory rate of 22/min. He is restless and his skin is warm. Which of the following are appropriate nursing interventions for this client? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to limit activity and rest. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.

1. A. CoRRECT: The provider may prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain culture specimens before antimicrobial therapy to prevent interference with the detection of the infection. B. INCORRECT: The nurse should increase oral fluid intake to replace the loss of body fluids from the diaphoresis and increased metabolic rate the fever can cause. C. CoRRECT: Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production. D.INCORRECT: The nurse should provide interventions to prevent shivering, because shivering increases energy demands. E. CORRECT: Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips.

2. A nurse is instructing an assistive personnel (AP) in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting her respirations." D. "Let the client rest for 5 minutes before you measure her blood pressure."

2. A. CoRRECT: The greatest risk to a client with a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa; therefore, the low platelet count contraindicates the use of the rectal route for this client. Of these instructions, this is the nurse's priority. B. INCORRECT: It is important for the AP to count the radial pulse, unless it is irregular, for 30 seconds and then multiply by 2 to obtain the number of pulsations per minute; however, there is a higher priority instruction among these options. C. INCORRECT: It is important for the AP to avoid letting the client know about counting respirations as this awareness can sometimes alter the respiratory rate; however, there is a higher priority instruction among these options. D. INCORRECT: It is important for the AP to let the client rest for 5 min before measuring blood pressure as activity can alter the reading; however, there is a higher priority instruction among these options.

2. A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions are appropriate for this client? (Select all that apply.) A. Suggest that his parents room in with him. B. Provide a television and DVDs for him to watch. C. Limit visitors to immediate family. D. Devise a regular schedule for inpatient routines. E. Allow him to perform his own morning care.

2. A. INCORRECT: Rooming in is more appropriate for younger children. B. CORRECT: Nonviolent DVDs are appropriate diversional activities for an adolescent. C. INCORRECT: There is no reason to restrict visitors. Allowing his friends to visit helps prevent feelings of isolation. D. INCORRECT: Flexible routines and activities, such as wearing his own clothes and having his favorite snacks on hand, help adolescents feel more comfortable in inpatient settings. E. CORRECT: Allowing him to perform his own morning care helps promote a sense of independence.

2. A nurse is admitting an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following questions should the nurse ask to investigate the source of his weight loss? (Select all that apply.) A. "Do you eat alone or with someone?" B. "Do you watch television while eating your meals?" C. "Have you started any new medications in the past 6 months?" D. "What foods have you eaten within the past 24 hours?" E. "Are you on a fixed income?"

2. A. CORRECT: Clients who eat alone are more likely to skip or skimp on meals. B. INCORRECT: Determining if the client watches TV while eating is not relevant in this situation. C. CORRECT: Many medications affect the senses of taste and smell, as well as the abilities to tolerate food and to absorb nutrients. D. CORRECT: Asking about food the client ate within the last 24 hr will provide a basis to determine what he typically eats in a 24‐hr period. E. CORRECT: Clients who receive a fixed income may not have enough money to buy food.

2. A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following capabilities? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Feel frustrated that time is too short for attempting to start another life. C. Welcome opportunities to be creative and productive. D. Commit to finding friendship and companionship. E. Become involved with community issues and activities.

2. A. INCORRECT: Acceptance of diminished strength and increased dependence is a developmental task crucial for older adults. B. INCORRECT: Feeling frustrated that time is too short affects adults who are having difficulties with the developmental tasks of middle age. C. CoRRECT: Psychosocially healthy middle adults accept life's opportunities for creativity and productivity and use these opportunities for achieving Erikson's stage of generativity vs. stagnation. D. INCORRECT: Seeking and forming friendships is a developmental task crucial for young adults. E. CoRRECT:Psychosocially healthy middle adults achieve Erikson's stage of generativity vs. stagnation by

2. A client asks the nurse what her Snellen eye test results mean. Her visual acuity is 20/30. Which of the following responses is appropriate? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 ft what visually unimpaired eyes see at 20 ft." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

2. A. CORRECT. The first number is the distance in feet the client stands from the chart. The second number is the distance at which a visually impaired eye can see the line clearly. B. INCORRECT: Each eye has its own visual acuity, which includes both numbers. C. INCORRECT: The numerator of visual acuity results is a constant. It does not change with a client's ability to see clearly. D. INCORRECT: Each eye has its own visual acuity, which includes both numbers.

2. A nurse in a provider's office is documenting his findings following an assessment he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status

2. A. CoRRECT: Posture is part of the body structure or general appearance portion of the general survey. B. CoRRECT: Skin lesions are part of the body structure or general appearance portion of the general survey. C. CoRRECT: Speech is part of the behavior portion of the general survey. D. INCORRECT: Allergies are part of the health history, not the general survey. E. INCORRECT: Immunization status is part of the health history, not the general survey.

2. A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (Select all that apply.) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive dryness and wrinkling

2. A. INCORRECT: Aging skin does become thin and translucent, but this typically does not affect tenting. B. CoRRECT: Tenting is a delay in the skin returning to its normal place after pinching. It can be a sign of aging skin and loss of subcutaneous tissue that provides recoil in younger skin. C. CoRRECT: Tenting is a delay in the skin returning to its normal place after pinching. It can be a sign of dehydration, which easily develops in older adult clients for many reasons. D. CoRRECT: Tenting is a delay in the skin returning to its normal place after pinching. It can be a sign of aging skin and its loss of elasticity. E. INCORRECT: Aging skin does become dry and wrinkled, but this typically does not affect tenting.

2. A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

2. A. INCORRECT: Rhonchi are coarse sounds that result from fluid or mucus in the airways. B. INCORRECT: Crackles are fine to coarse popping sounds that result from air passing through fluid or re-expanding collapsed small airways. C. CoRRECT: Resonance is the expected percussion sound over the thorax. It is a hollow sound that indicates air inside the lungs. D. CoRRECT: Tactile fremitus is an expected vibration the nurse can expect to feel as the client vocalizes. Speech creates sound waves, the vibrations of which travel from the vocal cords through the lungs and to the chest wall. E. CoRRECT: Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways.

3. A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion

3. A. INCORRECT: Olfaction is the use of the sense of smell to detect any unexpected findings that the nurse cannot detect via other means, such as a fruity breath odor. Unless there is an open lesion on the client's abdomen, this is not the next step in an abdominal examination. B. CoRRECT: Because palpation and percussion can alter the frequency and intensity of bowels sounds, the nurse should auscultate the abdomen next - and before using those two techniques. C. INCORRECT: Palpation is the next step in examining other areas of the body, but not the abdomen. D.INCORRECT: Percussion is important for detecting gas, fluid, and solid masses in the abdomen, but it is not the next step in an abdominal assessment

3. A nurse is talking with an adolescent who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I kind of like this girl in my class. She doesn't like me back, though, not that way." B. "I like hanging out with the guys in the science club, but the jocks pick on them." C. "I just don't seem to be any good at anything. I can't play any sports at all." D. "My dad wants me to be a lawyer like him, but I don't want to learn all that stuff."

3. A. INCORRECT: It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of forming peer relationships and dating relationships. This problem is not the priority for assessment and intervention. B. INCORRECT: It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of becoming part of a peer group and establishing a group identity. This problem is not the priority for assessment and intervention. C. CORRECT: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of the school-age years to develop industry (such as by learning new skills and experiencing achievements in them) vs. inferiority. This adolescent is still struggling with this task and needs assistance in working through that dilemma. D. INCORRECT: It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of forming an identity that will lead to higher education and a career. This problem is not the priority for assessment and intervention.

3. A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-Fowler's position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 1 min if it is regular. E. Count and report any sighs the client demonstrates.

3. A. CoRRECT: Having the client sit upright facilitates full ventilation and gives the students a clear view of chest and abdominal movements. B. CoRRECT: With the client's arm across the abdomen or lower chest, it is easier for the students to see respiratory movements. C. CoRRECT: Observing for one full respiratory cycle before starting to count assists the students in obtaining an accurate count. D. INCORRECT: The students should count the rate for 1 min if it is irregular. E. INCORRECT: An occasional sigh is an expected finding in adults. It helps expand small airways. Students needn't count nor report sighs.

3. A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretion D. Far vision E. Glomerular filtration

3. A. Correct. In middle adulthood, metabolism declines and weight gain is likely. B. INCORRECT: In middle adulthood, the ability to hear high-pitched sounds declines. C. CoRRECT: In middle adulthood, decreases in secretions of bicarbonate and gastric mucus begin and persist into older age. This increases the risk of peptic ulcer disease. D. INCORRECT: In middle adulthood, near vision declines (presbyopia). E. CoRRECT: Middle adults begin to lose nephron units, which results in a decline in glomerular filtration rates.

3. A nurse is planning a presentation to a group of older adults at a senior community center about the essential screening tests and preventive procedures during this stage of life. Which of the following should the nurse include? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Eye examination D. Mental health screening E. Dual-energy x-ray absorptiometry (DEXA) scanning

3. A. INCORRECT: HPV typically affects people in their teens and early 20s, so it is not a recommendation for older adults. B. CORRECT: Older adults are especially susceptible to pneumococcal infections, so this is an essential preventive measure for this stage of life. C. CORRECT: Screening for glaucoma via regular eye examinations is essential for older adults. D. CORRECT: Screening for depression via mental health assessments is essential for older adults. E. CORRECT: Screening for osteoporosis via DEXA scanning is essential for older adults.

3. A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension of the trachea on both sides of the midline

3. A. CoRRECT: The thyroid gland lies in the anterior portion of the lower half of the neck, just in front of the trachea. B. INCORRECT: An average-size thyroid gland is not visible on inspection. C. INCORRECT: A bruit indicates increased blood flow, possibly due to hyperthyroidism. D. CoRRECT: When the client swallows a sip of water, the nurse should feel the thyroid move upward with the trachea. E. CoRRECT: The thyroid gland lies in front of the trachea and extends symmetrically to both sides of the midline.

3. A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system? (Select all that apply.) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature

3. A. INCORRECT: Determining range of motion helps the nurse evaluate joint function, not circulation. B. CoRRECT: Assessing the peripheral vascular system to verify adequate circulation to the client's legs includes skin color. Pallor and cyanosis reflect inadequate circulation. C. CoRRECT: Assessing the peripheral vascular system to verify adequate circulation to the client's legs includes edema. Edema reflects inadequate venous circulation. D. INCORRECT: Inspecting for skin lesions is part of an integumentary assessment, but it does not evaluate circulation. Some skin lesions do reflect inadequate circulation, but they would not have developed in the immediate postoperative period. E. CoRRECT: Assessing the peripheral vascular system to verify adequate circulation to the client's legs includes skin temperature. Coolness of the extremity compared with the nonoperative extremity indicates inadequate circulation.

4. A nurse is performing a comprehensive physical examination for an older adult. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) A. Perform the assessments in one continuous session. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take her time answering questions. E. Invite the client to use the bathroom before beginning the examination.

4. A. INCORRECT: The nurse should perform the various parts of the assessment in several shorter segments to avoid overtiring the client. B.CoRRECT: Because many older adults have mobility challenges, the nurse should plan the session to allow extra time for position changes. C. CoRRECT: The nurse should make sure older adults who use sensory aids have them available for use. The client has to be able to hear the nurse and see well enough to avoid injury D.CoRRECT: Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication. E. CORRECT: This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who might have a diminished bladder capacity.

4. A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase iron intake to prevent anemia. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

4. A. INCORRECT: Older adult women do not need as much iron as they did when they were menstruating. B. INCORRECT: Older adults should increase fluid intake to prevent dehydration and constipation. C. CoRRECT: Older adults are at risk for osteoporosis. Increasing calcium intake is one way to help prevent it. D. CoRRECT: Older adults are at risk for edema and hypertension. Limiting sodium intake is one way to help prevent them. E. CoRRECT: Older adults should increase fiber intake to prevent constipation.

4. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a middle adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type b B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza

4. A. INCORRECT: The CDC recommends Haemophilus influenzae type b immunizations during infancy and not generally beyond 18 months of age B. CoRRECT: The CDC recommends varicella (chickenpox) immunizations during middle adulthood. C. CoRRECT: The CDC recommends herpes zoster (shingles) immunizations during middle adulthood, typically one dose at age 60 or beyond. D. INCORRECT: The CDC recommends human papilloma virus (genital warts) immunizations during adolescence and young adulthood. E. CoRRECT: The CDC recommends seasonal influenza immunizations during middle adulthood.

4. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza

4. A. INCORRECT: The CDC recommends rotavirus immunizations during infancy and not generally beyond 8 months of age. B. CoRRECT: The CDC recommends varicella (chickenpox) immunizations during adolescence. C. INCORRECT: The CDC recommends herpes zoster (shingles) immunizations during middle adulthood, typically one dose at age 60 or beyond. D. CoRRECT: The CDC recommends human papilloma virus (genital warts) immunizations during adolescence. E. CoRRECT: The CDC recommends seasonal influenza immunizations during adolescence.

4. A nurse is reviewing the various types of lesions nursing students might encounter when performing integumentary assessments for their clients. Which of the following lesions should the nursing students recognize as vesicles? (Select all that apply.) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella

4. A. INCORRECT: Acne lesions are pustules, not vesicles. B. INCORRECT: Warts are nodules, not vesicles. C. INCORRECT: Psoriasis lesions are scales, not vesicles. D. CORRECT: Herpes simplex lesions are vesicles, which are circumscribed fluid-filled skin elevations. Eczema and impetigo also cause vesicles to appear on the skin. E. CORRECT: Varicella (chickenpox) lesions are vesicles, which are circumscribed fluid-filled skin elevations. Eczema and impetigo also cause vesicles to appear on the skin.

4. A nurse who is admitting a client who has a fractured femur obtains a blood pressure (BP) reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive medication. B. Ask the client if she is having pain. C. Request a prescription for an anti-anxiety medication. D. Return in 30 min to recheck the client's BP

4. A. INCORRECT: If the client's BP remains elevated after the nurse implements other interventions to reduce it, it might be appropriate to request a prescription for an antihypertensive medication. However, there is a higher priority action among these options. B. CoRRECT: The greatest risk to a client with a fracture is unrelieved pain, which can cause multiple complications, including elevated BP. Therefore, the nurse's priority is to perform a pain assessment. If the client's BP is still elevated after pain interventions, the nurse should report this finding to the provider. Of these instructions, this is the nurse's priority. C. INCORRECT: If the client's BP remains elevated after the nurse implements other interventions to reduce it, it might be appropriate to request a prescription for an anti-anxiety medication. However, there is a higher priority action among these options. D. INCORRECT: If the client's BP remains elevated after the nurse implements other interventions to reduce it, it is appropriate to recheck the client's BP in 30 min and periodically thereafter. However, there is a higher priority action among these options.

5. A nurse at an elementary school is planning a health promotion and primary prevention class. Which of the following topics are appropriate to include for the parents of school-age children? (Select all that apply.) A. Childhood obesity B. Substance use disorders C. Scoliosis screening D. Front-seat seatbelt use E. Stranger awareness

5. A. CoRRECT: Parents of school-age children need to be aware of nutritional strategies for preventing childhood obesity. B. CoRRECT: Parents of school-age children need to know how to teach children to say no to illegal drugs, alcohol, and all other harmful or addictive substances. ​​ C. CoRRECT: School-age children and adolescents require screening for scoliosis. D. INCORRECT: Children younger than 13 years are safest in the back seat. ​​E. CoRRECT: Parents need to reinforce stranger safety as soon as their children are old enough to understand it, and throughout all stages of childhood.

4. A nurse is talking with the parents of a 10-year-old child who express concern that their son is suddenly becoming secretive, for example, closing the door when he showers, dresses, and does his homework in his room. Which of the following responses by the nurse is appropriate? A. "Perhaps you should try to find out what he is doing behind those closed doors." B. "Suggest that he leave the door ajar for his own safety." C. "At this age, children tend to become more modest and value their privacy." D. "Tell him it's okay to close the door when he is undressed, but he has to do his homework where you can see him."

4. A. INCORRECT: This response unnecessarily casts suspicion and implies that the child is doing something wrong. B. INCORRECT: This response unnecessarily suggests that the child has something to fear in his own home. C. CoRRECT: From a developmental perspective, it is an expectation that school-age children develop privacy. They have their own way of doing things and spend more time alone. D. INCORRECT: This suggestion sounds like a punishment, and the parents have not presented any evidence that the child is doing anything wrong.

4. During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur

4. A. INCORRECT: To auscultate a ventricular gallop (an S3 sound), the nurse places the bell of the stethoscope at each of the auscultatory sites. B. CoRRECT: To auscultate the closure of the mitral valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. C. INCORRECT: To auscultate the closure of the pulmonic valve, the nurse places the diaphragm of the stethoscope over the aortic area, which is just to the right of the sternum at the second intercostal space. D. CoRRECT: To auscultate the closure of the tricuspid valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. E. INCORRECT: To auscultate a murmur, the nurse places the bell of the stethoscope at various auscultatory sites.

4. A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions are appropriate? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone

4.A. INCORRECT: The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years. B. CoRRECT: Inserting the speculum slightly down and forward follows the natural shape of the ear canal. C. INCORRECT: The nurse should insert the speculum 1 to 1.5 cm (0.4 to 0.6 in). D. CoRRECT: The lining of the ear canal is sensitive. Touching it with the speculum could cause pain. E.CoRRECT: Due to the angle of the ear canal, the nurse can only visualize the light reflecting off of the tympanic membrane as a cone shape rather than a circle.

5. A nurse is preparing a wellness presentation for families at a community center. When discussing health screenings for adolescents, which of the following information about scoliosis should the nurse include? (Select all that apply.) A. Scoliosis is more common among girls than it is among boys. B. Loss of height is often the first sign of scoliosis. C. Scoliosis screening is essential during the adolescent growth spurt. D. Slouching is a common cause of scoliosis, especially in adolescents. E. Scoliosis is a forward curvature of the spine.

5. A. CORRECT: Girls are more likely than boys to have adolescent idiopathic scoliosis. B. INCORRECT: Loss of height is often the first sign of osteoporosis. Asymmetry in shoulder or hip height is a sign of scoliosis. C. CORRECT: Idiopathic scoliosis is most noticeable during the adolescent growth spurt. D. INCORRECT: In most cases, scoliosis has no apparent cause. E. INCORRECT: Scoliosis is a lateral curvature of the spine.

5. A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min and her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

5. 16/min: The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84 - 68 = 16

5. A nurse is counseling a middle adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my son expects me to relive my parenting days."

5. A. INCORRECT: It is common for middle adults to face the challenge involved in adjusting to and caring for aging parents. This problem is not the priority for assessment and Intervention. B. CoRRECT: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of young adulthood to develop intimacy vs. isolation. This middle adult is still struggling with this task and needs assistance in working through searching for and developing intimate relationships with others. C. INCORRECT: It is common for middle adults to face the challenge involved in contributing to their community. This problem is not the priority for assessment and intervention. D. INCORRECT: It is common for middle adults to face the challenge involved in questioning their ability to contribute to future generations in a grandparenting role. This problem is not the priority for assessment and intervention.

5. A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits

5. A. CoRRECT: Tympany is the expected drumlike percussion sound over the abdomen. It indicates air in the stomach. B. CoRRECT: Typical bowel sounds are high-pitched clicks and gurgles occurring about 35 times/min. C. INCORRECT: Borborygmi are unexpected loud, growling sounds that indicate increased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation, and reactions to some foods. D. INCORRECT: Friction rubs result from the rubbing together of inflamed layers of the peritoneum and are unexpected findings. E. INCORRECT: Bruits indicate narrowed blood vessels and are unexpected findings

5. A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

5. A. INCORRECT: Aging brings decreases in skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, thin, transparent skin. B. CoRRECT: With aging, height decreases due to the thinning of intervertebral disks. C. INCORRECT: Saliva production diminishes with age, making xerostomia (dry mouth) a common problem. D. CoRRECT: Aging brings thickening of the nails of the fingers and toes, and also changes their shape, color, and growth rate. E. CoRRECT: While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL.

5. A nurse is instructing a group of nursing students in the priorities of care in performing an integumentary assessment for their clients. Which of the following findings should the students recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema

5. A. INCORRECT: Pallor can indicate anemia or circulation difficulties. These are important and require intervention, but there is a higher priority among these options. B. CORRECT: The priority finding when using the airway, breathing, circulation (ABC) approach to care delivery is one that affects the client's airway. Cyanosis can reflect hypoxia (inadequate oxygenation), so nurses must take immediate action to report the finding and improve the client's oxygenation. C. INCORRECT: Jaundice can indicate liver dysfunction or red blood cell destruction. These are important and require intervention, but there is a higher priority among these options. D. INCORRECT: Erythema usually indicates inflammation. This is important and requires intervention, but there is a higher priority among these options.

5. A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of the client's skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers

5. A. INCORRECT: The palmar surface of the hands is especially sensitive to vibration, not temperature. B. INCORRECT: The fingertips are sensitive to pulsation, position, texture, size, and consistency, not temperature. C. CoRRECT: The dorsal surface of the hand is the most sensitive to temperature. D. INCORRECT: The base of the fingers is especially sensitive to vibration, not temperature.

5. A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

5.A. INCORRECT: The nurse should expect an older adult's gums to be pale. B. INCORRECT: The nurse should expect an older adult's vocal pitch to rise. C. CoRRECT: Tooth loss and gum disease are common in older adults. D. CoRRECT: Older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. E. CoRRECT: Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals.

2. A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for school-age children? (Select all that apply.) A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Shaping modeling clay

A. CoRRECT: Building simple models is appropriate for school-age children and helps develop fine motor and cognitive skills. ​B. CoRRECT: Playing video games, especially educational and nonviolent ones, is appropriate for school-age children and helps develop fine motor and cognitive skills. ​​C. CoRRECT: Reading books is appropriate for school-age children and helps develop cognitive and communication skills. ​​D. INCORRECT: Using toy carpentry tools is more appropriate for preschoolers. ​​E. INCORRECT: Shaping modeling clay is more appropriate for preschoolers

5. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio

A. CoRRECT: The CDC recommends human papillomavirus immunizations during adulthood. This virus, which causes genital warts, is most prevalent during adolescence and young adulthood. B. CoRRECT: The CDC recommends measles, mumps, rubella immunizations during adulthood. C. CoRRECT: The CDC recommends varicella (chickenpox) immunizations during adulthood. D. INCORRECT: The CDC recommends Haemophilus influenzae type b immunizations during infancy and not generally beyond 18 months of age. E. INCORRECT: The CDC recommends polio immunizations during childhood, but not generally beyond 18 years.

Chapter 21 1. A nurse is talking with parents of a school-age child who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? A. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping." B. "Our son keeps trying to find ways around our household rules. He always wants to make deals with us." C. "We think our son is trying too hard to excel in math just to get the top grades in his class." D. "Our son is always afraid the kids in school will laugh at him because he likes to sing and write little poems."

A. CoRRECT: When using the urgent vs. nonurgent approach to client care, the priority issue is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage of development. According to Erikson, it is a task of the preschool stage to develop initiative vs. guilt. This school-age child is still trying to develop the physical abilities he needs to feel a sense of accomplishment. He is still struggling with this task and needs assistance with motor skills and agility. B. INCORRECT: It is common for school-age children to fail to understand the reasoning behind many rules and to try to find ways around them and make the best deal. This problem is not the priority for assessment and intervention. C. INCORRECT: It is common for school-age children, who are in the stage Erikson describes as industry vs. inferiority, to strive to develop a sense of industry through advances in learning. This problem is not the priority for assessment and intervention. D. INCORRECT: It is common for school-age children, who are in the stage Erikson describes as industry vs. inferiority, to face the challenge of acquiring new skills and achieving success socially. This problem is not the priority for assessment and intervention.

2. A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between and being responsible for two generations

A. INCORRECT: Active involvement in the next generation is a developmental task for middle adults. B. INCORRECT: Adjusting to major role changes is a developmental task for older adults. C. CORRECT: Exploring career options and then establishing oneself in a specific occupation is a major developmental task for a young adult. D. INCORRECT: Assuming responsibility for the previous as well as the next generation is a developmental task for middle adults.

4. A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home.

A. INCORRECT: Although bath rails and grab bars add a measure of safety to bathing activities, this recommendation is specific for the older adult population due to their risk for falls. B. CoRRECT: Wearing a helmet while skiing helps reduce the risk of head injury. Although it applies to other age groups, many young adults engage in winter sports, so this is an age-appropriate recommendation for this developmental group. C. CoRRECT: Having a carbon monoxide detector in the home is an essential safety precaution for young adults as well as for all other developmental stages. D. CoRRECT: Securing firearms in a safe location helps reduce the risk of accidental gunshot injuries. Although it applies to all age groups, many young adults own firearms, so this is an age-appropriate recommendation for this developmental group. E. INCORRECT: Although throw rugs can pose a safety hazard, this recommendation is specific for the older adult population due to their risk for falls.

3. A nurse is reviewing nutritional guidelines with the parents of an 11-year-old child. Which of the following parents' statements should indicate to the nurse that they understand the guidelines for school - age children? A. "She wants to eat as much as we do, but we're afraid she'll soon be over weight." B. "She skips lunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner." C. "We limit fast-food restaurant meals to three times a week now." D. "We reward her school achievements with a point system instead of a pizza or ice cream."

A. INCORRECT: By the end of the school-age stage, parents should expect children to eat adult-size portions of food. B. INCORRECT: Skipping meals can lead to unhealthful snacking and overeating later in the day. C. INCORRECT: Parents should avoid fast-food restaurants completely to keep children from eating food high in sugar, fat, and starches. D. CoRRECT: Parents should avoid rewarding children with food for good behavior or achievements. Associations children form between food and feeling good can lead to weight problems.

3. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My girlfriend is pregnant, and I don't think I have what it takes to be a good father."

A. INCORRECT: It is common for young adults to face the challenge of leaving home and establishing independent living. This problem is not the priority for assessment and intervention. B. INCORRECT: It is common for young adults to face the challenge of transitioning from being single to being a member of a new family. This problem is not the priority for assessment and intervention. C. CORRECT: When using the urgent vs nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of adolescence to develop identity vs role confusion. This young adult is still struggling with this task and needs assistance in working through that dilemma. D. INCORRECT: It is common for young adults to face the challenge involved in questioning their ability to parent. This problem is not the priority for assessment and intervention.

3. During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

A. INCORRECT: With fat, there are rolls of adipose tissue along the sides, and the skin does not look taut. B. INCORRECT: With fluid, the flanks also protrude, and when the client turns onto one side, the protrusion moves to the dependent side. C. CoRRECT: With flatus, the protrusion is mainly midline, and there is no change in the flanks. D. INCORRECT: With hernias, protrusions through the abdominal muscle wall are visible, especially when the client raises her head.