NCLEX Prep: Client Needs: Health Promotion & Maintenance

The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? Select all that apply.

The average newborn weighs between six to nine pounds (2,700 to 4,000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13 to 14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.

A client in active labor arrives in the birthing unit, and birth is imminent. What is the most important question for the nurse to ask at this time?

"When is your baby's expected date of birth? It is most important to know whether this is a preterm or full-term pregnancy so appropriate preparations may be made for the neonate. Asking whether this is the client's first baby is irrelevant at this time. Although the client may be asked whether her membranes have ruptured, it is not the priority when a birth is imminent, and prematurity must be known to enable appropriate preparations. The birth is imminent, so asking when her contractions began is also irrelevant at this time.

A nurse is teaching a parent about promoting safety in adolescents. Which statements made by the parent indicate the need of further teaching? Select all that apply.

"I should limit my child's interaction with adults. "I should allow my child to freely socialize with peers. The nurse should tell the parent to encourage mentoring relationships with adults. Adolescents need to socialize with their peers and yet need some supervision. Hence, when the parent says that an adolescent's interaction with adults should be limited and that the adolescents should be allowed to freely socialize with peers, these indicate the need for further teaching. The nurse should inform the parents to be aware of their child's risk-taking behaviors and peer pressures. Parents should be aware of the injuries in this age-group related to motor-vehicle accidents. Parents should teach their child about overuse and possible exposure to inappropriate websites.

Which dietary suggestion should the nurse provide while teaching a group of geriatric female clients who have reduced amounts of circulating estrogen?

"Include yogurt in your diet.Clients ages 65 years or older are referred to as geriatric. Females usually attain menopause at the age of 55 years. Due to reduced amounts of circulating estrogen in postmenopausal women, bone density decreases, thus increasing the risk of osteoporosis. Geriatric clients should be advised to consume foods rich in calcium such as yogurt, which helps support increases in bone mass. Fish is a good source of omega-3-fatty acids, which maintains a healthy heart. Fruits are rich in fiber, which prevents constipation. Fiber is good for a client's overall health. Legumes are a good source of protein and strengthen the body. However, these dietary suggestions for elderly female clients are less beneficial when compared to the consumption of yogurt.

In order to implement primary prevention of STIs (sexually transmitted infections) a nurse is counseling an adolescent. What would be the priority nursing action?

Assess the adolescent's sexual risk behaviors The priority step for primary STI prevention is to assess the sexual risk behavior of the adolescent to identify the risk factors and provide appropriate counseling accordingly. With that information in mind, the nurse can then help the adolescent recognize the risk, encourage usage of preventive measures, and provide proper information about STIs.

A client with kidney dysfunction is about to undergo renal testing using a contrast medium. Which nursing interventions should be conducted before the procedure to ensure the client's safety? Select all that apply.

Assessing the client for a history of cirrhosis Asking the client if he or she has a known shellfish allergy Assessing the client's hydration status by checking blood pressure and respiratory rat While interviewing a client who is about to undergo kidney procedure using a contrast medium, the nurse should assess for a history of cirrhosis. Clients with cirrhosis have an increased chance of developing kidney failure after the procedure. The nurse should confirm any known shellfish allergies because contrast dye administered during the study may cause nephrotoxicity. It is not necessary to check the client for a history of lactic acidosis when ensuring the client's safety for renal testing. If the client had lactic acidosis currently, then this would be a significant factor when ensuring the client's safety for renal testing. The nurse should also assess the client's hydration status by checking blood pressure and respiratory rate. The nurse should ask the client to discontinue metformin 24 hours before the procedure to prevent lactic acidosis.

What is the priority nursing action during a client's second stage of labor?

Assessing the perineum for bulging A bulging perineum is caused by the pressure of the fetal head against the perineal area and usually signifies imminent birth. Pain medication is not administered this close to the birth; it crosses the placental barrier and can cause respiratory distress in the newborn. During the second stage of labor the client is encouraged to push, not pant, with each contraction. Catheterization may be indicated earlier in labor so uterine contractions are not impeded; voiding will occur spontaneously as the client pushes.

What is the nurse's priority assessment for a client in the fourth stage of labor?

Distention of the bladder A distended bladder impedes contraction of the uterus, predisposing the client to hemorrhage. Relaxation is a priority before birth; in the fourth stage the client is often euphoric. It is too soon to assess breast engorgement because it occurs on the third or fourth postpartum day. It is too soon to assess bonding; this progresses with care and responsibility.

What nursing intervention is appropriate for a child going through the stage of autonomy versus sense of shame and doubt?

Guide the parents to help the child achieve self-control and willpower The nurse guides the parents to help the child to achieve self-control and willpower during the autonomy versus sense of shame and doubt stage. The nurse helps parents cope with the hospitalization of an infant during the trust versus mistrust stage. The nurse helps hospitalized adolescents make decisions about their treatment plan during the identity versus role confusion stage. The nurse assists physically ill adults in choosing creative ways to foster social development during the generativity versus self-absorption and stagnation stage.

In what ways can a nurse prevent medication errors? Select all that apply.

Minimize the use of verbal and telephone orders Avoid using abbreviations and acronyms Check three times before giving a drug by comparing the drug order and medication profile The use of abbreviations is avoided because this action may cause confusion and increase the risk of error. The use of verbal and telephone orders should be minimized to avoid confusion over drugs that have similar names. Before a drug is administered, the dosage order should be checked three times to verify the five rights: right drug, right dose, right time, right route, and right client. The use of trailing zeros should be avoided because it increases the risk of overdose. If the client's language is not understood, a translator's help should be enlisted.

Which statements regarding the adverse effects of immunization are true? Select all that apply.

Paralytic poliomyelitis is caused only by the poliovirus vaccine; it occurs when the live vaccine undergoes mutation in the intestine and enters the central nervous system. The swelling of glands in the cheeks and neck is a mild adverse effect of the measles vaccine. Almost all vaccines cause fever and erythema at the injection site; these effects are the result of activation of the body's defense mechanism. Acute encephalopathy is a serious side effect of not only the diphtheria vaccine but also the tetanus toxoid and acellular pertussis vaccine. Hepatitis B, with only mild side effects, is one of the safest vaccines.

What nursing action is the priority for a client in the second stage of labor?

Promote effective pushing by the client Effective pushing will hasten the passage of the fetus's presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will depress the newborn's respirations. Although the mother may breastfeed after the birth, during the second stage of labor she should be concentrating on the birth process, not feeding the infant.

A nurse assesses a child who is scheduled to receive the diphtheria, tetanus, and pertussis vaccine. After an assessment, the nurse concludes that the child cannot receive the vaccine safely. Which assessment finding supports the nurse's conclusion?

The child has a history of anaphylactic reactions after vaccinations Vaccines are contraindicated in children who exhibit anaphylactic reactions because these reactions may be life-threatening. If a fever develops after a child's first vaccination, subsequent vaccines should be administered with caution. If a shock-like state has previously developed after a vaccination, subsequent vaccines should be administered with caution. When a child has an upper respiratory tract infection, vaccinations may be postponed until the infection is resolved.

What important points should the nurse keep in mind when caring for an older adult to promote health? Select all that apply.

The nurse should encourage the client to include physical activity regularly and to use stress-management strategies to promote a healthy lifestyle. The nurse should consider the client's social environment and strengthen social support to promote health. Because a fear of falling is a significant risk related to older adults, the nurse should assess the client for fear and provide support by making environmental changes. The nurse should not focus on the absence of a disease, but on achieving the highest level of health in the presence of disease. The nurse should encourage older adults to perform activities of daily living on their own to promote health.