Practice Assessment: 2019 RN VATI Health Promo/Maintenance - End of Review

A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

"Daily jogging for up to 30 minutes is fine throughout the pregnancy." While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods.

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

"I'll feed my baby every 2 hours." Breast engorgement is relieved by emptying both breasts. The client might be able to accomplish this with more frequent feedings. Otherwise, she can pump her breasts after breastfeeding to ensure optimal emptying.

A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make?

"It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. The nurse should reassure the parents that regression is an expected behavior in children who are hospitalized and that her child will regain bladder control when she is feeling better.

A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?

"This is a normal, expected reaction for a child of this age." The 8-month-old child is exhibiting a normal response to separation from the parent by protesting loudly. Explaining this expected separation anxiety reaction to the parent might help the parent to cope with feelings of guilt when leaving the child's bedside.

A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to provide 1 oz of grains. Which of the following foods should the nurse recommend?

1 cup ready-to-eat cereal flakes The child should eat 1 cup of ready-to-eat cereal flakes to consume 1 oz of grains.

A nurse is teaching a group of adults about nutrition. The nurse should include which of the following amounts as an appropriate daily intake of fiber for adult women?

20 to 35 g The Adequate Intake (AI) for total fiber for women is 25 g per day

A nurse is instructing a group of clients about nutrition. The nurse's teaching plan should state that in order to limit saturated fat intake, the client should limit total fat intake to what percentage of total calories per day?

30% In order to limit saturated fat intake, the total percentage of fat intake per day is 35%.

A nurse participating in lead screening at a community center. The nurse should instruct parents to bring their children back for rescreening in a year for which of the following laboratory values?

4 mcg/dL A child who has a lead blood level of 4 mcg/dL should return in a year for rescreening.

A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for a vitamin B6 deficiency?

A client who has chronic alcohol use disorder. The nurse should recognize that alcohol consumption destroys and increases elimination of vitamin B6 from the body; therefore, this client is at risk for vitamin B6 deficiency.

A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?

A client with a weight of 150 lb and height of 68 inches The formula for calculating BMI is weight in kilograms divided by the height in meters squared. The formula to convert pounds to kilograms is to divide the weight in pounds by 2.2 kilograms. The formula for converting inches to meters is to multiply the total inches times 0.0254 meters. 150 pounds divided by 2.2 equals 68.18 kilograms. 68 inches multiplied times 0.0254 inches equals 1.7272 meters. 1.7272 meters (squared) is 2.983 meters. 68.18 kilograms divided by 2.983 meters equals a BMI of 22.85. A BMI of 18.5-24.9 is considered a healthy weight.

A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

A needleless syringe and a doll Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child, because they will allow the child to act out feelings of anger and helplessness.

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

Albumin Albumin levels reflect the overall body protein status and is used to detect metabolic and liver dysfunction.

A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?

Artificial lubrication can be used to treat vaginal itching and dryness. The nurse should instruct the client that atrophic vaginal changes occur due to the loss of estrogen postoperatively and can also cause pain and dryness during sexual intercourse. Artificial lubricants can reduce the manifestations associated with diminished mucous production.

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

At the end. When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows.

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

Breasts can be examined in the shower with soapy hands. The nurse should encourage clients to perform a BSE or do an extra examination while showering. This allows clients to concentrate more easily on feeling for tissue changes. The nurse should instruct clients to report breast dimpling or discharge. Changes in the texture of breast tissue are associated with menses, menopause, hormone replacement therapy, and pregnancy. The nurse should instruct clients who have a menstrual cycle to perform a BSE every month, about 7 days after menstruation ends. The nurse should instruct clients to use the sensitive finger pads of the middle three fingers to perform a BSE.

A nurse is providing dietary teaching to a client who has nephropathy secondary to diabetes mellitus and plans to make dietary adjustments. Which of the following instructions should the nurse include?

Consume less than 0.8 g/kg of body weight of protein per day. Clients who have diabetes should adjust protein intake to less than 0.8 g/kg of body weight per day to delay renal injury. Diabetics should consume between 45% to 65% of carbohydrates per day. Clients who have diabetes should limit cholesterol to less than 200 mg per day. Clients who have diabetes should reach the goal of 25 g per day of fiber for women and 38 g per day for men.

A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause?

Dryness with intercourse Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries stop making estrogen. Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse.

A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times?

Every morning before arising To measure basal temperature, the client must take her temperature every morning at the same exact time before getting out of bed. The client must try not to move too much, as any activity can raise the body temperature slightly.

A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following is a trigger for the formation of vitamin D in the body?

Exposure to sunlight Exposure to sunlight triggers the formation of vitamin D in the body.

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations?

Facial edema Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider.

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?

Ignore the temper tantrums. Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly.

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client?

Large building blocks Large building blocks are age-appropriate toys for a 12-month-old toddler.

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?

Lower left quadrant The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal contents from the rectum causes pouch formation.

A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?

Meningococcal polysaccharide vaccine Recent studies have shown that college students, especially freshmen living in dormitories, are at an increased risk for meningococcal meningitis. The Centers for Disease Control and Prevention and the American Academy of Pediatrics now recommend that college students and parents be educated about meningococcal disease and consider vaccination.

A nurse is caring for a client who is on a 2,000-calorie American Diabetes Association (ADA) diet and substitutes the whole milk on his breakfast tray with skim milk. Because of this substitution, the nurse should know that the client can add which of the following items to the oatmeal on his breakfast tray?

One tablespoon low-fat margarine Substituting skim (fat-free) milk for whole milk allows the client to add a fat exchange to his breakfast tray. A fat exchange usually varies in serving size, but one tablespoon of low-fat margarine is considered one fat exchange.

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

Orthopnea A toddler who has heart failure has increased venous return to the heart and lungs, which leads to pulmonary congestion. The congestion causes orthopnea, or difficulty breathing, while lying down. Having the toddler sit up decreases venous return, as well as pressure the abdominal organs have on the diaphragm. This decrease in pressure improves breathing and oxygenatio

A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet?

Peanut butter and jelly sandwich A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Peanut butter is an excellent source of protein. A peanut butter and jelly sandwich, especially if prepared on protein-enriched bread, can provide almost 20 grams of protein.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?

Swimming Some exercises, such as swimming and walking, can help clients who have low back pain because they strengthen back muscles.

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

Variable decelerations are due to umbilical cord compression. Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.