Wellness exam 1

posterior fontanel closes around

2-3 m of age

by which month is the babies gross motor skills include: raises head and shoulders off mattress when prone, only slight head lag

3 m

by which month is the babies gross motor skills include: roll from front to back

5

by which month is the babies gross motor skills include: rolls from back to front

6

by which month is the babies gross motor skills include: bears full weight on feet, sits, leaning forward on both hands

7

pincer grasp develops around

8 m

A mother tells the nurse that her 2-year-old toddler has temper tantrums and says "no" every time the mother tries to help her get dressed. The nurse should recognize, the toddler is manifesting which of the following stages of development? A. Trying to increase her independence. B. Developing a sense of trust. C. Establishing a new identity. D. Attempting to master a skill.

A

A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? A. "My baby loved to play with his crib gym, but I took it away from him." B. "I just bought a soft mattress so my baby will sleep better." C. "My baby really likes sleeping on the fluffy pillow we just got for him." D. "I put the baby's car seat out of the way on the table after I put him in it."

A

A nurse is talking with parents of a 12-year-old child. Which of the following issues verbalized by the parents should the nurse identify as the priority? 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."

A

A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? A. Establish consistent boundaries for the toddler. B. Place the toddler in a room with the door closed. C. Inform the toddler how you feel when he misbehaves. D. Use favorite snacks to reward the toddler.

A

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply). A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery.

A B

A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply). A. Obtain a periodic mental status evaluation. B. Discuss prevention of sexually transmitted infections. C. Regularly screen for tuberculosis. D. Provide education about drug and alcohol use. E. Teach monthly breast examinations for girls.

A B C D

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (Select all that apply). A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A B C E

A nurse is planning a health promotion and primary prevention class for the parents of school-age children. Which of the following information should the nurse include? (Select all that apply). A. Provide information about the risk of childhood obesity. B. Discuss the danger of substance use disorders. C. Promote discussion about sexual issues. D. Recommend the school age child sit in the front seat of the car. E. Reinforce stranger awareness.

A B C E

A nurse is planning diversionary activities for school-age children on an impatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply). A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Playing board games

A B C E

A profession has specific characteristics. In regard to, how nursing meets these characteristics, which criteria are consistent and standardized processes? (Select all that apply.) a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism

A B C E Nursing as a profession has a code of ethics, licensing, a body of knowledge, and altruism. Because there are multiple paths of education for nursing and not a standard entry into practice, this is one criterion of a profession that is not standard and consistent.

A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply). A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers

A B D

A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply). A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care

A B D

A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply). A. Rolls from back to front B. Bears weight on legs C. Walks holding onto furniture D. Sits unsupported E. Sits down from a standing position

A B D

A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply). A. Suggest that his parents bring in video games for him to play. B. Provide a television and DVDs for the adolescent to watch. C. Limit visitors to the adolescent's immediate family. D. Involve the adolescent in treatment decisions when possible. E. Allow the adolescent to perform his own morning care.

A B D

A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select all that apply). A. Poor wound healing B. Dry hair C. Blood pressure 130/80 mmHg D. Weak hand grips E. Impaired coordination

A B D E

Of the following, which are included in the ANA standards? (Select all that apply.) a. a. Standards for professional performance b. b. Code of ethics c. c. Standards of care d. d. Legal scope of practice e. e. Licensure requirements

A C ANA standards have two parts: one is standards for professional performance, and the other is standards of care. ANA has a separate document that is a code of ethics. Nurse practice acts are a legal scope of practice.

A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply). A. Store toxic agents in locked cabinets. B. Keep toilet seats up. C. Turn pot handles toward the back of the stove. D. Place safety gates across stairways. E. Make sure balloons are fully inflated.

A C D

A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply). A. Assembling puzzles B. Pulling wheeled toys C. Using musical toys D. Playing with puppets E. Coloring with crayons

A C D E

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply). A. Eye examination every 1 to 3 years B. Decrease intake of calcium supplements C. DXA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders.

A C D E

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 protein intake to increase muscle mass. 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.

A C D E

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 secretions D. Far vision E. Glomerular filtration

A C E

A nurse is assessing from a 2-week-old newborn during a routine checkup. Which of the following findings should the nurse expect? (Select all that apply). A. Sleeps 14 to 16 hr each day. B. Posterior fontanel closed C. Pincer gasp present D. Hands remain in a closed position E. Current weight same as birth weight

A D E

A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits. B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity. C. Providing specialized intraoperative training regarding surgical treatments for obesity. D. Educating acute care nurses on postoperative complications related to obesity.

A primary health care emphasizes health promotion and disease control.

A nurse is teaching a group of women about risk factors for developing osteoporosis. Which of the following risk factors should the nurse include? (Select all that apply). A. Inactivity B. Family history C. Obesity D. Hyperlipidemia E. Cigarette smoking

A. B. E.

The most commonly reported illicit drugs are a. marijuana and hashish. b. oxycontin and oxycodone. c. fentanyl and oxycontin. d. Robitussin with codeine and Tylenol with codeine.

ANS: A Although marijuana is being prescribed in some states it is not a widely used prescription drug, nor is hashish. All other options are incorrect as they are federally regulated drugs and require a prescription to be obtained legally.

The nurse determines that which question is the most appropriate way to begin a sexual assessment of an older adult? a. "How has your sexual function changed as you have become older?" b. "Do you find it embarrassing to talk about sexual activity?" c. "Do you ever feel pressured or unsatisfied during sexual activity?" d. "Would it be okay if I asked you some questions about your sexual health?"

ANS: A An open-ended question provides the patient with the opportunity to respond with more data than a closed-ended question. The remaining three choices are all closed-ended questions that do not foster conversation.

A father is upset because his preschool son has told him he wishes he were gone and pushes him and his wife apart whenever they are together. What advice should the nurse give the father? a. This is normal at this age and should resolve on its own. b. The child may need counseling to resolve his conflict. c. Tell the child this is inappropriate and will not be tolerated. d. The child needs to go to preschool to separate from his mother.

ANS: A In the preschool years, feelings of resentment toward the parent of the same sex often occur as the child develops a strong bond with the parent of the opposite sex. As the child matures, these feelings usually resolve on their own. This is not something that requires counseling. Setting limits with hostile behavior may be appropriate, but parents need to understand that this is part of the Oedipus/Electra complex in development at this age. Sending the child to preschool will aid in socialization but will not force the child to separate from the mother.

The hallmark of the older adult populations is a. increases in diversity. b. highest death rates in the U.S. c. Alzheimer's disease. d. urinary incontinence.

ANS: A The hallmark of the older adult population is the increase in diversity. Older minority individuals are living longer than majority older adults especially after age 85. Older adults do not have the highest death rates in the U.S. Alzheimer's is seen in some older adults but not the majority. Not all older adults experience urinary incontinence.

While doing her morning assessment, the nurse shares with her patients the tests and procedures they have scheduled for that day as well as when she expects to return to deliver their medications or do their treatments. Even though the hospital is a hectic and difficult environment to predict, the nurse regards this information session with her patients as an important way to demonstrate she cares. The rationale behind her action is a. to increase the patients' sense of security by making the environment more predictable for the patients. b. to ease her patients' fears since they may worry that she'll forget to give them their medications. c. to point out to her patients that the care they are receiving is consistent and delivered on time so they will rate her care higher when they leave the hospital. d. to allow the patients some flexibility in when they want to take their medications or have their tests and procedures done.

ANS: A The nurse is informing the patients about the day's schedule so they will know what to expect. The idea is to increase the predictability of an otherwise hectic and unpredictable environment. "To ease her patients' fears since they may worry that she'll forget to give them their medications" is incorrect since there's nothing in the stem of the question that indicates the patients are afraid she'll forget. "To point out to her patients that the care they are receiving is consistent and delivered on time so they will rate her care higher when they leave the hospital" is incorrect since the nurse's intention is to show the patients that she cares; this is not a patient-centered rationale but is intended to boost the nurse's satisfaction ratings. "To allow the patients some flexibility in when they want to take their medications or have their tests and procedures done" is incorrect since the patients are not being given options about when things will happen but are only being told in advance what will happen and when.

When a 52-year-old man asks the nurse if some sexual positions are considered perverted, the nurse replies by saying many people enjoy different positions for sex and that each couple has the right to use any position for sex that they enjoy. In consideration of the PLISSIT model for counseling patients with sexual problems, of what is the nurse's response an example? a. Limited information b. Specific suggestion c. Permission giving d. Intensive therapy

ANS: A The nurse's response is providing limited information to dispel this patient's misconception. The other steps listed occur, but they are different components of the PLISSIT model.

3. Which statement below is not true about fluid intelligence? a. Increases throughout middle adulthood b. Supports reasoning, abstraction, and problem solving c. Represents basic information-processing skills d. Peaks in adolescence and progressively declines beginning around age 30

ANS: A This statement is true about crystallized intelligence, which increases throughout middle adulthood as adults add to their knowledge base. All other options are true characteristics of fluid intelligence.

A nurse is gathering an admission assessment on a patient who recently emigrated from Japan and is a Buddhist. The man told the nurse that he normally meditates daily and lives almost exactly the way he did in Japan. However, he has not been able to walk for the past weeks. Based on the assessment findings, which questions would be important for the nurse to ask before implementing his nursing care? (Select all that apply.) a. What have you done to cope with your health problem? b. What do you call your health problem? What do you think is wrong? c. What concerns you most about the recommended treatment plan? d. What do you think caused your health problem?

ANS: A, B, C, D All assessment questions fit the scenario and are questions the nurse should explore with a patient who describes himself as someone from a very different culture and religion than the dominant health care culture. The patient should be given the opportunity to describe what he thinks is wrong and what he expects in terms of treatment. The nurse also needs to collect data on what health remedies the patient has tried to cope with the problem and anything that might concern him about the plan of care the nurse has developed.

A nurse is planning a program for educating a Hispanic community regarding nutritional practices. What would be the most important aspects that the nurse takes into consideration first? (Select all that apply.) a. Change theory and Health Belief Model b. Previous educational programs c. Cultural influences d. Hospital admissions from this community

ANS: A, C Since the nurse will be discussing nutrition to a specific cultural group, the nurse needs to understand the cultural influences on their nutritional practices. In addition the nurse needs to understand change theory to plan her education if she is attempting to have the group make changes in their nutritional practices. The Health Belief Model would also help in understanding the community's perceptions regarding barriers that facilitate or discourage adoption of the promoted behaviors.

The nurse recognizes the importance of a patient's beliefs in influencing the patient's behaviors and responses to health care problems. Which of the following are examples of a patient's beliefs? (Select all that apply.) a. A patient explains that the medication he is taking is helping him overcome his anxiety. b. A patient reflects on her values and uses them to help her make a decision about whether or not to have breast reconstruction surgery. c. A patient expresses a feeling of dread about the future to his nurse. d. A 78-year-old man signs a "Do Not Resuscitate Order" when he learns he's had a massive heart attack because, he explains, "he can hardly wait to go and be with his wife in heaven."

ANS: A, D "A patient explains that the medication he is taking is helping him overcome his anxiety" is correct because it describes a man who believes in the effectiveness of using medications that have been scientifically tested to help alleviate health problems such as anxiety. "A 78-year-old man signs a 'Do Not Resuscitate Order' when he learns he's had a massive heart attack because, he explains, 'he can hardly wait to go and be with his wife in heaven'" is correct because it describes a man whose religious beliefs helped him decide against undergoing life prolonging treatments because he says he believes in an afterlife in "heaven." "A patient reflects on her values and uses them to help her make a decision about whether or not to have breast reconstruction surgery" is incorrect because it describes a woman who used "values clarification" to help make a decision about her health care. "A patient expresses a feeling of dread about the future to his nurse" is incorrect because a feeling of dread is "anxiety" and is not a belief.

A nurse recognizes the importance of active listening as a way to show the nurse cares. Which of the following actions by the nurse describes active listening? (Select all that apply.) a. Sitting at the patient's bedside and listening to the patient talk while inserting an IV b. Sitting in a chair facing a patient and making a mental note of the major points of the conversation c. Listening to what the patient says and what he means while she conducts her early morning assessment d. Engaging both the patient and the family members while taking careful notes of the conversation

ANS: B Active listening means doing nothing else but listening to the patient. It's about being attentive and engaged. "Sitting at the patient's bedside and listening to the patient talk while inserting an IV" is incorrect because the nurse is doing something else while the patient talks. "Listening to what the patient says and what he means while she conducts her early morning assessment" is also incorrect because the nurse is also conducting an early morning assessment while listening. "Engaging both the patient and the family members while taking careful notes of the conversation" is incorrect because the nurse is attending to note taking instead of only listening.

4. Strategies for stress relief when caring for an aging parent include all of the following except: a. Seek social support b. Place him or her in a nursing home c. Use community resources d. Utilize respite care services

ANS: B Nursing home placement should be used as a last resort. The idea of placing an aging parent in a nursing home can bring on provider guilt, which is a stressor. Also, nursing placement can be taxing on the finances of the family. All the other options may be available for stress relief for the caregiver of aging parents.

Which of the following statements regarding older adults is not true? a. Common causes of death include heart disease, stroke, and influenza. b. Chronic illnesses include arthritis, COPD, and STDs. c. Declines in the immune system make older adults susceptible to infections. d. Acute injuries are often the result of falls and pneumonia.

ANS: B STDs are not among the chronic illnesses seen in older adults. Heart disease, stroke, and influenza are common causes of death in older adults. Declines in the immune system do make older adults more susceptible to infectious disease. Falls and pneumonia are the cause of most acute illnesses in older adults.

A 16-year-old male patient has been involved in a motor vehicle accident. Every time the nurse enters his room, there are at least 4-5 friends laughing and talking with the patient. The nurse is frustrated in trying to get things done. What is the nurse's best action? a. Call security to escort the visitors from the room. b. Work with the boy and his friends to plan and coordinate activities to minimize interruptions. c. Ask the boy's parents to tell his friends to stay away. d. Post a "Do not disturb" sign on the door.

ANS: B Teenagers have strong bonds with peer groups, and this continues even with hospitalization. The best approach is to plan activities so as to minimize interruptions. Respecting the teen's need for socialization encourages better communication and understanding between the nurse and the patient. The other options do not facilitate open communication and trust.

In examining a 3-month-old infant, you would expect to see all of the following except: a. Raising chest and head when prone b. Responding to own name c. Social smile d. Bringing hand to mouth

ANS: B The child responds to his or her own name at about 7 months. The other selections are all behaviors seen at or before 3 months of age.

A nursing student walks into the patient's room and is unsure about when it is appropriate to use caring touch in a nurse-patient care situation. What should the student do? a. Leave the room and ask her clinical instructor when and where she should touch her patient. b. Ask the patient for permission to touch her before proceeding. c. Disregard the use of touch since she is unsure of how to maintain professional boundary when it comes to touching a patient. d. Assume all patients want to be touched and that they see it as an act of caring.

ANS: B Whenever a nurse is unsure about the use of touch, it's always best to ask the patient's permission. "Leave the room and ask her clinical instructor when and where she should touch her patient" is incorrect since the nursing instructor is not there and would not know the patient any better than the student. "Disregard the use of touch since she is unsure of how to maintain professional boundary when it comes to touching a patient" is incorrect since "caring touch" is an important way nurses convey they care. To disregard it is to ignore an important means of communication. It is better that the student keep practicing and gaining experience in using touch in order to learn how and when to use it to let her patients know she cares. "Assume all patients want to be touched and that they see it as an act of caring" is incorrect since not all patients want to be touched. The nurse should develop the skills of being able to read the patient's body language and when unsure, to ask permission.

A hospitalized patient comments to the nurse, "Well, I guess my sex life is over." Which response would the nurse determine to be the most appropriate initial response? f. a. "I am sorry to hear that." g. b. "Tell me why you say that." h. c. "Oh, you have a lot of good years left." i. d. "Have you asked your doctor about that?"

ANS: B Encouraging the patient to share information or feelings is an appropriate therapeutic communication technique. Sympathy and using a cliché may not encourage communication. Asking about interaction may be helpful, but it is not the most appropriate initial nursing response.

A co-worker is an excellent nurse but often assumes responsibility for other people's irresponsible behaviors. Her nurse manager notices that in the past several months she has become overly sensitive with her patients and that she complains of feeling stressed and worn out because she has taken on too much. She admits to having a family background that makes her suspect she has some co-dependent traits. How should her nurse manager proceed if the nurse's work continues to suffer? a. The manager should offer her emotional support for as long as she needs it. b. Help her recognize that she may be co-dependent and needs to get professional help. c. Take her to the next scheduled group therapy session in the mental health ward. d. Confront her about her inappropriate behavior and threaten to fire her if her work doesn't improve.

ANS: B From the scenario, the nurse needs help to recognize that she may be co-dependent and that it is impacting her work performance and the way she's treating her patients. She needs to seek out professional counseling. "The manager should offer her emotional support for as long as she needs it" is incorrect because the nurse manager needs to refer her for treatment and not drag out the situation indefinitely, which is implied in the answer. "Take her to the next scheduled group therapy session in the mental health ward" is incorrect since the nurse manager should not take responsibility away from the nurse but encourage the nurse to take responsibility for herself, which is the best way she can learn to help others. "Confront her about her inappropriate behavior and threaten to fire her if her work doesn't improve" is incorrect since it is not supportive but aggressive and confrontational in nature. The manager wants to help the nurse return to being an excellent nurse again and that would not happen if the manager fires her.

When the nurse teaches sexually transmitted disease (STD) prevention, which unimmunized individual would be identified as being at the highest risk for contracting the human papilloma virus (HPV)? a. A prepubescent 11-year-old child b. A sexually active 21-year-old college student c. A 42-year-old celibate divorced person with hypertension d. A 28-year-old monogamous married truck driver who has type 2 diabetes

ANS: B HPV is transmitted by sexual intimacy. According to the CDC, men and women can lower their risk of getting HPV by being in a monogamous, faithful relationship. Of the individuals mentioned, the 21-year-old who is sexually active is the most likely candidate to get the disease, regardless of gender.

The nurse is teaching a patient about sexually transmitted diseases. Which of the following statements, if made by the nurse, could lead to the spread of STDs? (Select all that apply.) a. Always use latex condoms. b. If you don't have any symptoms then you probably don't have an STD. c. All HPV infections are low risk infections. d. There is no cure for HPV.

ANS: B, C Some viruses such as HIV and HPV may be dormant for years before symptoms are seen and HPV viruses are classified as low risk or high risk. "Always use latex condoms" and "There is no cure for HIV" are true statements and this knowledge may reduce risky sexual behaviors and limit the spread of STDs.

What is the nurse's role as patient advocate? (Select all that apply.) a. Explain to the patient the nurse's viewpoint. b. Provide necessary education and interpret information. c. Accept the patient's decision and support his or her wishes. d. Give the patient the physician's explanation of his or her viewpoint.

ANS: B, C The nurse as the patient advocate must first provide education and interpret information in an unbiased manner. Then the nurse must accept the patient's decision and support his or her wishes even if it is different from the nurse's own viewpoint or that of other health care personnel.

How might a nurse as a researcher approach the care of the patient? (Select all that apply.) a. Performing technical skills as learned b. Looking for problems and questioning practices c. Incorporating research she has read into her practice d. Carrying out procedures as they always have been done

ANS: B, C By looking for problems and questioning practices, the nurse is identifying problems that can be researched. By incorporating any new research into practice, the nurse is involved in evidence-based practice.

The term "ageism" refers to a. the act of getting older. b. the hallmark of older adult populations. c. prejudices and stereotypes applied to individuals based on their age. d. octogenarians.

ANS: C Ageism is a word coined by Dr. Robert Butler and is defined as prejudices and stereotypes applied to people sheerly on the basis on age. Getting older is aging. An increase in diversity is the hallmark of the older population in the U.S. Octogenarians refers to people living 80+ years.

The nurse is caring for an 11-year-old girl in a hospital. The nurse finds a bunch of gum wrappers in her bedside stand. Which is the most appropriate action by the nurse? a. Reprimand the girl for being so sloppy. b. Quietly clean up the mess and throw them away. c. Leave the wrappers as you found them. d. Tell the girl to clean up the mess.

ANS: C School-age children enjoy sorting and categorizing objects of different sorts, which manifests itself in collecting objects. This patient is collecting gum wrappers. The other options would be upsetting to the child.

A kindergartener's mother is concerned because the child has had two bouts of respiratory infections in the past three months since school started. What is the nurse's best response? a. "His immune system should be stronger by now; I think we will need to do some further screening." b. "His immune system is compromised because his schedule has changed. Be sure he gets to bed on time." c. "He is exposed to more germs now that he is in school. Let's go over good handwashing." d. "You should talk to the school about disinfecting the classroom."

ANS: C The kindergartener is exposed to more pathogens when he or she enters school. It is not unusual to see an increased rate of infections when the child begins school. It is not an indication of immune system compromise in an otherwise healthy child. Although disinfecting the classroom is useful in outbreaks of disease, reinforcement of proper handwashing is the most effective way to reduce the spread of common childhood illnesses.

The nurse informs a group of men at the senior citizens' center about what age-related sexual change? a. Increased testosterone levels b. More frequent erections c. Weaker erections d. Sperm production increases

ANS: C Weaker erections in older men occur due to physiologic changes associated with aging. As men age, their testosterone level decreases, they need more time to achieve erection and ejaculation, and sperm production decreases.

. Sexual health history questions would be most relevant for the nurse to include when admitting a patient who is taking what type of medication? a. Hypnotics (sleeping pills) b. Antihistimines (cold medications) c. Antihypertensives (blood pressure medication) d. Antiinflammatories (such as aspirin or ibuprofen)

ANS: C Many antihypertensive medications have erectile dysfunction as a side effect. Anti-inflammatory, hypnotic, and antihistamine medications do not have erectile dysfunction as a side effect.

Nursing students all belong to National Student Nurses Association when they are attending a specific nursing program. This is an important aspect of their socialization to the profession as it demonstrates which criteria of a profession? a. Providing service to society b. Accepting responsibility for actions and omissions c. Participating in an organization that supports and advances the profession d. Making independent decisions based on their scope of practice

ANS: C Students begin their socialization to the profession by participating in an organization, which is one criteria of a profession.

The nurse is caring for a 35-year-old married male, father of one, who has been admitted for a vasectomy. Though he is seeking this procedure of his own free will, the nurse's personal moral standards indicate this is wrong. What would be the most appropriate action by the nurse when caring for this patient? a. Have the hospital chaplain speak with this patient. b. Remind the patient that he has time to still change his mind. c. Provide the patient with appropriate care, realizing the decision is personal. d. Tell the patient about all the males in the infertility clinic who would be envious of his situation.

ANS: C Therapeutic communication indicates that the nurse must not be judgmental when interacting with the patient. Communicating with the chaplain may be helpful in some cases but should not be used by the nurse to avoid patient interaction. Reminding the patient that there is time to change his decision interjects the nurse's personal beliefs and biases. It is judgmental and belittling to note that others would be envious.

A team meeting of physicians and nurses is convened to discuss a specific patient's problems and to determine goals for the patient. During the meeting, specific accountability related to patient care for both the physicians and nurses involved is established. All members of the meeting show mutual respect by valuing each other's clinical competence that is necessary to provide quality patient care. Of the following functions of a nurse, which one is demonstrated in the above example? a. Delegation b. Advocacy c. Collaboration d. Management

ANS: C This is an example of the dynamic interpersonal process of collaboration in which health care professionals constructively solve problems and learn from each other.

Which statement by a patient indicates an accurate understanding of contraceptive methods? a. "Hormonal injections are an effective defense against sexually transmitted infections." b. "Abstinence is never an effective method of contraception when used as a periodic or continuous strategy." c. "Withdrawal of the penis before ejaculation is an ineffective method of birth control that does not reduce the potential spread of sexually transmitted infections." d. "Oral contraceptives protect against pregnancy by stimulating ovulation, thinning cervical mucus, and allowing a fertilized egg to move through the uterus to the fallopian tube."

ANS: C Withdrawal is not effective as a method of contraception and does not reduce the spread of sexually transmitted diseases. The remaining statements are false.

A parent of a preschool child is concerned because his teachers have complained about his aggressive behavior toward other children. Which of the following pieces of information is most important in helping the parent determine possible sources of this behavior? a. The types of playmates the child has b. The kinds of toys the child plays with c. Whether or not the child is allowed to roughhouse with his siblings d. The types of television programs the child watches

ANS: D Media sources, including television programs, often show aggressive behavior that the child will imitate. It is important to determine the amount and types of television programs the child watches daily. The child will often emulate these behaviors in play. The other answers are usually not major contributors to childhood aggressive behavior.

Which of the following actions by the nurse demonstrates "doing for" as described in Swanson's theory? a. Going the extra mile b. Thoroughly assessing in order to know what the patient thinks c. Seeking cues and expertise from colleagues about the patient's condition d. Preserving the patient's dignity and performing competently

ANS: D The "doing for" process of Swanson's theory includes preserving the patient's dignity and performing competently. The other answers are either part of the caring process or are part of the practice of knowing the patient.

The best approach for a nurse who is performing an assessment on a patient from an ethnic group the nurse knows nothing about is to a. use the information the nurse already knows about the other ethnic groups that may be similar to the patient's group to come up with assessment questions. b. ask the same questions the nurse typically asks of all patients and not deviate from the questions on the assessment form. c. ask the patient to explain what he or she believes his or her health problem is and what he or she thinks caused it. d. ask the patient to help the nurse understand anything about the patient's ethnic group that may have a bearing on the patient's health care needs.

ANS: D The best strategy by the nurse is to approach the situation with humility and admit he knows nothing about the patient's ethnic group but would like to learn about anything that would be significant to the patient's care. "Use the information the nurse already knows about the other ethnic groups that may be similar to the patient's group to come up with assessment questions" is incorrect because it amounts to guessing or pretending rather than just admitting he doesn't know what he needs to in order to provide ethnically appropriate care. The result could mean the nurse would miss something important to the patient. "To ask the same questions the nurse typically asks of all patients and not deviate from the questions on the assessment form" is incorrect since it would completely ignore the patient's ethnic differences and would end in something important being missed. "Ask the patient to explain what he or she believes his or her health problem is and what he or she thinks caused it" is incorrect because it addresses the patient's health problem but doesn't include other ethnic-specific information that would be important in providing care for this patient.

A nurse has graduated from a nursing program and is participating in a new graduate program at a local hospital as a continuing socialization to the role of the nurse. At what level is the nurse functioning at this point in the nurse's career? a. Expert b. Competent c. Novice d. Advanced Beginner

ANS: D The nurse is an advanced beginner for 2 to 3 years after graduating and doesn't reach the level of competence until the end of that time period.

An 18-year-old patient tells the nurse that cocaine is used regularly to try to boost sexual performance. What statement does the nurse identify as true about the effects of cocaine on sexual performance? a. Cocaine has no effect on sexuality. b. Even a small amount of cocaine can cause impotence. c. Cocaine can reduce sex hormone levels and sperm production. d. Chronic cocaine use results in sexual dysfunction and loss of desire in both men and women.

ANS: D The repeated use of cocaine decreases sexual function and desire in both genders. Cocaine does have an impact on sexuality due to reduced desire and function. Cocaine does not reduce sex hormone levels or sperm production and a small amount does not result in impotence.

Consequences of domestic violence include all of the following except: a. Unwanted/unplanned pregnancies b. STDs c. Drug abuse d. Type 1 diabetes and hyperglycemia

ANS: D Type 1 diabetes and hyperglycemia are the result of endocrine system defects. All other options are possible consequences of being a victim of domestic violence.

. _______________ syndrome is a neurotoxic disorder that has been linked to febrile illness and aspirin use in children less than 18 years of age.

ANS: Reye The presence of viral infection and the use of aspirin in children are linked to Reye syndrome, a potentially fatal toxic encephalopathy. Avoid use of aspirin and non-aspirin-containing salicylates during febrile illnesses in children.

From the nurse's knowledge about the emerging adult according to Arnett's theory, which behavior by a 21-year-old hospitalized male patient is most appropriate for his age group? a. Talking about college courses that he is taking while working part-time at a restaurant b. Requesting that his mom be present when his IV line is started c. Stating that he cares for his disabled father and his 2-year-old daughter d. Becoming upset that he is not giving back to his community

Answer: a According to Arnett (2006), emerging adults are shifting their choices, and many are unstable; they explore more possibilities and move gradually toward enduring choices. The young adult is often slow in transitioning due to pursuing higher education. This 21-year-old is pursuing education while working part time, which fits within Arnett's theory for this age group. A 21-year-old male would be exhibiting regression if he needed his mom with him during an IV start. Caring for his father and daughter would be more typical of middle adults, who are called the "sandwich" generation. Giving back to one's community is generativity, which is Erikson's middle adult developmental task.

When a patient reports having dyspareunia, which question is it most appropriate for the nurse to ask? a. "Have you talked with your partner about this discomfort?" b. "Have you had these spasms since you became sexually active?" c. "Does the bleeding continue longer than five days?" d. "Do your breasts swell up large enough for you to need a larger bra?"

Answer: a Dyspareunia is painful intercourse, and the sexual partner should be made aware of this to foster understanding and adjustment of sexual practices. Spasms, bleeding, and breast swelling are not associated with this condition.

A teenage girl faces a long hospitalization after surgery. How can the girl's continued development be fostered? a. Encourage her to write her feelings in a journal. b. Divert her attention by playing video games. c. Encourage her to work on craft projects. d. Make sure her parents are constantly by her side.

Answer: a Teenagers are capable of abstract thought and often find it helpful to verbalize their feelings either by talking or by journaling. Diverting her attention by playing video games and encouraging her to work on craft projects are measures that may be used to help her pass the time but are not methods of fostering teen development. A teen usually does not wish parents to be at his or her side constantly and may want some private time away from them.

Which action by a 3-month-old infant would the nurse interpret as an example of Piaget's stage of primary circular reaction? a. Deliberately placing the thumb into the mouth b. Accidentally kicking a ball c. Searching for an object under a blanket d. Shaking a rattlE

Answer: a The deliberate action of placing the thumb in the mouth elicits a pleasurable effect. Accidentally kicking a ball is not a deliberate action. Searching for objects and shaking a rattle occur at later stages.

A 57-year-old male patient who was hospitalized with an admitting blood pressure of 240/120 asked the nurse if his family could bring in some meat and vegetable dishes from home. He explained that he cannot eat the foods on the hospital menu because it is summer and the hospital is only offering chicken and fish, which in his culture are "hot" foods that will interfere with his healing. Which response by the nurse would best demonstrate an application of Leininger's theory? a. Discourage the family from bringing in food, explaining that the idea of "hot" and "cold" foods is a superstition without scientific basis. b. Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient's blood pressure is supported. c. Explain that the patient will need to have home-prepared foods evaluated by the dietary staff to ensure that they are acceptable options. d. Tell the family to bring in any foods they want, to help preserve the patient's cultural practices and dietary preferences.

Answer: b According to Leininger's theory, negotiation and adaptation are part of what nurses do to accommodate the patient's cultural ways of life. As long as the foods from home have low concentrations of sodium or other ingredients that are known to affect blood pressure, the nurse can accommodate the patient's beliefs and cultural dietary practices as well as the medical plan of care. Rejecting the patient's cultural traditions and/or accepting them without regard for the well-being of the patient are unacceptable actions. Food given to patients from family members does not need to be evaluated by the dietary staff before consumption.

The mother of a 5-month-old infant is concerned because her child is not yet sitting on his own. What is the nurse's best response to her concerns? a. Informing the mother that this is not normal and recommending further evaluation b. Telling the mother that this is normal development for a 5-month-old c. Encouraging the mother to do sit-ups with the child to encourage muscle development d. Asking the mother if the child had any trauma at birth

Answer: b According to the American Academy of Pediatrics, 7-month-olds will first sit with help and then sit on their own. A 5-month-old is not expected to sit alone. Although sit-ups may help muscle development, the child's neurologic system must develop enough to maintain a sitting position. Asking about birth trauma is not necessary because the child is not exhibiting delayed development. Asking about birth trauma would cause alarm and is not related to the child's ability to sit.

While assessing a patient for domestic violence, the nurse knows that which statement is true regarding domestic violence? a. It is a health risk factor only during young adulthood. b. It occurs across socioeconomic levels and cultural boundaries. c. Young women aged 20 to 24 have the lowest incidence of rape and sexual assaults. d. Women are the only victims of domestic violence whom nurses should be concerned about.

Answer: b All socioeconomic levels are affected by domestic violence. It is a health risk for adults of all ages from young to older adulthood. Young women have the highest rate of rape and sexual assault. Women are not the only victims of domestic violence. Men also may be victims of domestic violence and sexual assaults, although they are less likely to report it or to seek care.

A 1-year-old child grabs an Easter egg and attempts to throw it across the room. The nurse knows that the child is exhibiting which scheme according to Piaget? a. Adaptation b. Assimilation c. Accommodation d. Equilibration

Answer: b Assimilation occurs when the child attempts to use a new object in the same fashion as for a more familiar object. Adaptation is the process of adjusting schemes to new applications. Accommodation occurs when the child understands that the object is different from a more familiar object and cannot be used in the same way. Equilibration occurs when a balance is achieved between the old understanding and the new.

For which reason are patients unlikely to introduce the topic of sex with health care providers? a. Most patients have few, if any, questions or problems relating to this topic. b. They are too embarrassed to discuss the topic of sex with a health care provider. c. Female patients prefer to discuss problems with female health care providers. d. They assume that health care professionals know little about sexual functioning.

Answer: b Embarrassment to discuss a personal subject can cause the patient to avoid introduction of the topic. Gender is not a consideration in this question, and it cannot be generalized that patients have few questions or problems on any topics. Health care professionals generally are considered to be knowledgeable in subject matters associated with health and illness.

Which behavior by the young adult patient indicates an understanding of patient education aimed at reducing the health risks for that age group? a. Smoking only 1 pack of cigarettes per day b. Limiting alcohol use to an occasional drink c. Using drugs found in a roommate's drawer for anxiety d. Having a relationship with a partner who was threatening in the past

Answer: b Having an occasional drink shows control and moderation. Smoking any amount is damaging, and education for cessation is needed. Using any drugs that are not directly prescribed for the person shows a lack of understanding of the risks of drugs. Staying in a relationship that has been dangerous in the past increases the risk of intimate partner violence.

The nurse is performing a health assessment on a 15-year-old female patient. Which is the best way to obtain accurate information regarding her sexual activity? a. Ask the mother about the girl's sexual activity. b. Privately ask the girl about her sexual activity. c. Warn the girl about the dangers of sexual activity. d. Ask the girl if she wants birth control.

Answer: b Privately asking the girl about her sexual activity in an open and nonjudgmental fashion is the best way to obtain accurate information. Asking the mother about the girl's sexual activity may be embarrassing for the teen and her mother and may not provide accurate information. Warning the girl about the dangers of sexual activity is making a judgment. It is important to provide a nonjudgmental approach with teens. The teen may have additional questions about sexuality beyond the topic of birth control, so it is important to approach the teen in a manner that encourages open discussion.

Nurses need to understand how beliefs and values are different. A nurse begins to offer information to a patient and the patient says, "I've already heard all of that before and I don't agree with any of it." How should the nurse proceed? 3. a. Ask the patient to explain his values. 4. b. Ask the patient to explain what he believes. 5. c. Ask the patient about his prejudicial attitude. 6. d. Confront the patient about the values conflict he's experiencing.

Answer: b The purpose of the question is contained in the stem, to determine whether the student can distinguish between a belief and a value. By asking the patient to explain what he or she believes, the nurse is asking an open-ended question to find out what part of what the nurse is saying the patient believes and what part he or she does not believe. Asking the patient to explain his or her values is incorrect because there is no mention in the stem about the patient saying his or her values are different from what the nurse is trying to say. Asking the patient about his or her prejudicial attitude is incorrect because there is nothing in the stem that indicates a prejudicial attitude. Confronting the patient about the values conflict he or she is experiencing is incorrect because there is nothing in the stem that indicates the patient is experiencing a values conflict. He or she simply does not believe the same thing the nurse believes.

The nurse in the emergency department is caring for an 8-year-old who has had a serious asthma attack. When the nurse attempts to explain the problem to the child's mother, she smells cigarette smoke on the mother's breath. The nurse asks the mother if she has been smoking and the mother responds, "Yes, and I know they've told me before I can't smoke around him." What should the nurse do next? a. Ask the patient's mother what she values more, her child or her habit. b. Ask the patient's mother to explain what she believes about smoking and asthma. c. Ask the patient's mother about her prejudicial attitude toward smoking. d. Confront the patient's mother about the values conflict she's experiencing.

Answer: b The nurse should begin by asking the mother what she believes because the nurse does not know at this point. When working with a patient who has an addiction, the nurse should begin at the assessment phase of the nursing process and attempt to build a trusting relationship with the patient. Asking the mother what she values more, her child or her habit, is incorrect because the issue is not about the mother's values but about what she knows and what she believes. Asking the mother about her prejudicial attitude toward smoking is incorrect because there is nothing in the stem to indicate the mother is prejudiced toward or against smoking. Confronting the mother about the values conflict she is experiencing is incorrect because there is nothing in the question to indicate the mother is having a values conflict. She may not believe what the health care professionals are telling her or she may not believe that she can quit smoking. She may need to be convinced that she can do it, and the best way to make that happen is to build a trusting relationship with her rather than alienate her with accusatory remarks.

As the nurse explained the preoperative instructions to the patient, the patient's older brother suddenly stepped into the doorway and yelled, "People who go under the knife always die. Don't do it! They're going to kill you." What type of higher-order belief is the patient's older brother displaying? f. a. Distress g. b. Stereotype h. c. Prejudice i. d. Denial

Answer: b The patient's brother is making a generalization that is a stereotype, which is a belief about a person, group, or an event that is thought to be typical of all others in that group. Although it is true that people occasionally die during surgery, it does not always happen as the brother fears. Distress is incorrect; the male is distressed, but distress is not a higher-order belief. Prejudice is incorrect because a prejudicial belief is a preformed opinion, usually an unfavorable one, about an entire group of people based on insufficient knowledge. Denial is wrong because he is not in denial, which is defined as a behavior of refusing to admit something is true.

Which term indicates a mental health disorder that is frequently seen in older adults? a. Schizophrenia b. Bipolar disorder c. Depression d. Posttraumatic stress disorder

Answer: c Depression is one of the psychiatric illnesses appearing most frequently in the older adult population. Schizophrenia typically is seen in younger adult populations. Bipolar disorder is usually identified before age 65 years. PTSD can be seen in any age group and usually is related to previous experience of a traumatic event.

For which person seen at a physician's office appointment would patient and family education be most critical? a. A 24-year-old male patient with a cold virus and on no medications b. A 45-year-old male patient on metformin for type 2 diabetes for the past 3 years c. A 75-year-old female patient just prescribed the anticoagulant warfarin d. A 40-year-old male asthmatic patient diagnosed 10 years ago and on albuterol

Answer: c Educating the patient and family members to the side effects of anticoagulant warfarin and its potential for bleeding is a critical part of care for the 75-year-old female patient. A 25-year-old male patient is young, and his immune system has the potential to fight off a cold virus. Education about a cold versus the flu would be helpful but is not critical. A middle adult who has had diabetes and has been maintained on this medication for 3 years would have had education when he was first started on the medication. A patient who has been using asthmatic medication for the past 10 years is likely to be knowledgeable about the medication from previous use.

Which group is referred to as the "sandwich generation?" a. Older adults who are caretakers for their elderly parents b. Younger adults who are reexamining their life choices c. Middle adults who are caretakers for multiple generations of their family d. Younger adults who are changing employment constantly

Answer: c Middle adults who are caretakers for multiple generations of their family tend to be sandwiched in between the needs of children, grandchildren, and elderly parents, all of whom need their attention and care. This situation can lead to many health and financial problems for the middle adult family. Although older adults caring for their elderly parent also may experience significant stresses, they would not be called the sandwich generation unless they also were caring for younger members of their family. Younger adults may change jobs or middle adults may reexamine choices they have made, but these factors do not reflect the concept of the sandwich generation.

While performing a physical assessment on a female patient, the nurse finds several bruises on the patient's inner thighs that are in various stages of healing and suspects that the patient may be a victim of sexual abuse. What should be the nurse's first action? a. Refer the patient to a sexual counselor. b. Tell the patient about the safe house for women. c. Ask the patient to describe how she got the bruises. d. Report the abuse immediately to the proper authorities.

Answer: c The nurse's first action is to gather more data that can confirm or negate the suspicion of sexual abuse. The other actions also could be appropriate after additional information is obtained.

What is the best activity for a hospitalized school-age child to encourage continued appropriate development? a. Watching favorite television shows for 2 hours per day b. Keeping a journal of feelings while in the hospital c. Working on a paint-by-number project that can be completed in an afternoon d. Playing a favorite video game each afternoon

Answer: c The school-age child is in Erikson's stage of industry. He needs to work on projects that build a sense of accomplishment. A painting project that can be completed in one afternoon gives a sense of accomplishment. Although the other options are activities, they do not contribute to the primary developmental task of the school-age child: developing a sense of industry

Which statement best describes for new parents how and when children develop first-order beliefs? e. a. During infancy, and once developed, such beliefs seldom change f. b. From life experiences during the toddler and preschool years g. c. Throughout life from first-hand experiences and information provided by authority figures h. d. From teen and young-adult peer interaction and mentorship of professional role models

Answer: c Individuals develop first-order beliefs beginning in childhood and continue to acquire them throughout life from first-hand experiences and what they are told by various authority figures. Therefore, first-order beliefs are acquired throughout life and not just in infancy, the first years of life, or adolescence. They form as the result of life experiences and from information provided by people perceived as having authority.

Which nursing theory of care describes how the nurse's presence in the nurse-patient relationship transcends the physical and material world, facilitating the development of a higher sense of self by the patient? a. Swanson's Theory of Caring Processes b. Madeline Leininger's Cultural Care Theory c. Watson's Theory of Human Science and Human Care d. Travelbee's Human-to-Human Relationship Model

Answer: c One of the major concepts of Watson's Theory of Human Caring is described in the stem of the question. Watson's theory is based on a holistic paradigm in which both the nurse and the patient transcend time and the physical and material world. Swanson's theory focuses on practical ways the nurse can help the patient through the use of the five caring processes. Leininger's theory focuses on maintaining and preserving the patient's cultural practices and ways of living but never mentions transcending beyond the physical world. Travelbee's theory focuses on the nurse and the patient creating a relationship bond, but the only mention of transcendence is that the nurse and the patient must transcend the roles that each has assumed.

After admitting a homeless patient to the floor, the nurse tells a colleague that "homeless people are too dumb to understand instructions." What action should the colleague take first? e. a. Ignore the nurse's prejudicial comment without responding f. b. Offer to trade assignments and care for the homeless patient g. c. Ask the nurse about the patient's personal history assessment data h. d. Challenge the nurse's thinking, pointing out the ability of all people

Answer: c The colleague should first ask the nurse to share information about the patient's background. This should encourage the nurse to consider the feelings and values of the patient and hopefully help the nurse to view the patient as a total individual. Ignoring the statement, offering to change assignments, or challenging the nurse's statement does not promote an enhanced nurse-patient relationship and may prevent the nurse from professional growth or make the nurse defensive.

A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the primary care provider. Which characteristic of a professional is the nurse demonstrating? a. a. Autonomy b. b. Collaboration c. c. Accountability d. d. Altruism

Answer: c The nurse is demonstrating accountability by taking responsibility for the error and reporting it after an initial assessment of the patient. Criteria of a profession include altruism (public service over personal gain), autonomy (independence), accountability, and diversity; however, in this case, the nurse is demonstrating accountability. Although collaboration is important for the health care team, it is not a criterion for a profession.

A preschooler's mother is concerned because her child behaves in a mean fashion toward her younger brother. The mother states, "She acts like she has no sympathy for him!" What is the nurse's best response? a. "She is very young to exhibit sibling rivalry." b. "What does her brother do to her to make her act this way?" c. "Do you fight at home? She is probably imitating you." d. "Preschoolers are not capable of putting themselves in another's place."

Answer: d A characteristic of preschool thought is that it is egocentric. That is, preschoolers are not yet able to see a situation from another's point of view. Sibling rivalry commonly appears in the preschool period. The brother's behavior has no bearing on the mother's expressed concern. The child is not necessarily imitating adult behavior but is displaying appropriate developmental characteristics. transitions

Which core competency of advanced practice nursing is the Master of Science in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques? a. Leadership b. Ethical decision making c. Direct clinical practice d. Expert coaching

Answer: d A nurse educator who is teaching and counseling students is practicing expert coaching and guidance. A nurse educator with a master's degree practices the other competencies of leadership and ethical decision making in other situations. Although a nurse educator may also work as a nurse involved in direct patient care, this is not part of the educator role.

Which statement is the best resource for the nurse to use when determining appropriate nursing care for a transsexual patient? a. Gender identity is altered by acute psychosis. b. Sexual attraction is to individuals of both genders. c. Gonadal gender, internal organs, and external genitals are contradictory. d. Anatomy associated with sexual identity is not consistent with gender identity.

Answer: d A transsexual's sex organs do not match gender identity. Being a transsexual is not a psychosis. Transsexuals usually are attracted to persons of the gender opposite their own gender identity. Gonadal gender and internal and external organs are not in contradiction

A 75-year-old male patient reports decreased frequency of sexual intercourse, although he does not express dissatisfaction or difficulty. He seems a little embarrassed by the discussion but is engaged and asks some questions. Which nursing diagnosis does the nurse determine is most appropriate for this patient? a. Sexual Dysfunction b. Disturbed Body Image c. Sedentary Lifestyle d. Readiness for Enhanced Knowledge

Answer: d Because the patient is able to discuss the topic of reduced sexual frequency without noting difficulty or dysfunction, manages any embarrassment, is engaged in the conversation, and is able to ask questions, the most appropriate nursing diagnosis is Readiness for Enhanced Knowledge. These collective behaviors do not describe Sexual Dysfunction or Disturbed Body Image, and "sedentary lifestyle" is not a NANDA-I nursing diagnosis.

The nurse knows that which patient is an example of the Wear-and-Tear Theory of Aging? a. A patient who is dying of cancer at age 35 b. A 55-year-old who runs half-marathons c. A patient with depression and suicidal thoughts who is 65 d. An 88-year-old with heart failure, kidney failure, and osteoarthritis

Answer: d Dr. Weisman believed that aging occurred because of overuse and abuse to body and cells, and that this takes place on the cellular and organ systems level. An 88-year-old with multiple body system failure and damage would be exhibiting signs of wear and tear. A 35-year-old patient dying of cancer would not have overuse. A 55-year-old running in half marathons is not exhibiting wear and tear, although signs of overuse may emerge later in life. A 65-year-old person with depression is not exhibiting wear and tear. Emotional stressors are only one group of factors that can lead to aging and are not a component of the wear-and-tear theory.

A patient who had a hysterectomy 3 days ago says to the nurse, "I no longer feel like a real woman." Which response by the nurse would be most appropriate? a. "Don't worry about that. The feeling will probably go away." b. "You should talk to your doctor about how you feel." c. "I don't blame you. I would feel like half a woman also." d. "I hear your concern. Tell me more about your feelings."

Answer: d Providing an opportunity for communication with an open-ended response encourages the patient to discuss concerns. Telling the patient not to worry is dismissing those concerns and will hamper discussion. Agreeing with the patient also is nontherapeutic and does not foster dialogue. Telling the patient to talk with the doctor stops the chance of conversation and reduces the nurse's role in helping the patient to express feelings.

When a patient is beginning a regimen of an antidepressant medication, which information should the nurse include in the medication teaching as it pertains to sexuality? a. "Your partner will be pleased because your sexual functioning is going to improve." b. "You may find that your desire for sex will decrease while on this medication." c. "Your skin will probably become supersensitive to touch, so you may need to change your activity during sex." d. "You will be unable to have an erection while taking your antidepressants."

Answer: d Reduced sexual desire can be a side effect of antidepressant use. Skin sensitivity and erectile dysfunction are not side effects. Improved sexual function is not a specific effect of antidepressant administration.

In Swanson's Caring Theory, the nurse demonstrates caring using several techniques. Which of the following is (are) included in the five caring processes? (Select all that apply.) a. Call patients by their first name to demonstrate a caring attitude. b. Sit at the bedside for at least 5 minutes each hour. c. Use touch based on the nurse's judgment of what is appropriate. d. Ask the patient to identify the most important thing to accomplish during the nurse's shift.

Answer: d The answer is based on the idea that the patient should always, whenever possible, be included in developing the plan of care and especially in setting his or her own goals. The other three answers are close, but something is wrong with each one. Calling patients by their first name to demonstrate a caring attitude is incorrect because the nurse should call each patient by his or her preferred name. Sitting at the bedside for at least 5 minutes each hour is incorrect because the nurse should sit at the bedside for 5 minutes each shift rather than each hour. Using touch based on the nurse's judgment is wrong because the nurse should allow the patient to decide how much touch is appropriate.

Which factor(s) is/are likely to influence the transition from adolescence to adulthood? (Select all that apply.) a. Cultural beliefs b. Societal values c. Personal beliefs and expectations d. Governmental rules e. Societal expectations

Answers: a, b, c Cultural beliefs, societal values, and personal beliefs and expectations are all factors that influence an individual's transition into adulthood. Although governmental rules may influence certain societal values and beliefs, they are not directly responsible for the transition through adulthood. Coté states that little is socially expected during this time, so routes to adult roles and responsibilities are highly diverse.

When an injury to a child is suspicious for abuse, which is/are important to document? (Select all that apply.) a. Size and location of bruising b. Distinguishing characteristics of injuries c. Height and weight of the child d. Time of last meal e. General state of health of the child

Answers: a, b, c, e The size and location of the bruising, distinguishing characteristics of injuries, height and weight of the child, and the general state of health of the child all are considerations in determining possible child abuse or neglect. The exact location and the nature of the injury are important to document. A child who has been abused over time may be small and have other health problems stemming from the abuse. The time of the last meal may be important information but usually is not related to suspected abuse.

The nurse is caring for a group of older adults. Which patient(s) in this group is/are exhibiting normal signs of aging? (Select all that apply.) a. The patient with knee pain and wrinkles around the eyes b. The patient who needs reading glasses and states that the food tastes bland c. The patient who is confused and does not know the current year d. The patient who states that constipation is an increasing problem e. The patient who is showing signs of depression and hopelessness

Answers: a, b, d Normal aging includes signs of decline in many organ systems. Knee pain, skin wrinkles, need for reading glasses, decline in taste buds, and constipation all can occur with aging. Normal aging does not include dementia or depression, even though these can both be diagnosed in the older adult population.

Which factors affect the nursing shortage? (Select all that apply.) a. a. Aging faculty b. b. Increasing elderly population c. c. Job satisfaction due to adequate number of nurses d. d. Aging nursing workforce e. e. Greater autonomy for nurses

Answers: a, b, d The nursing workforce and nursing faculty are aging. The entire population is aging, which increases the need for more nurses. The insufficient number of nurses leads to job dissatisfaction and burnout.

Which of the following statements describes a component discussed in nursing theories? (Select all that apply.) a. Optimal functioning of the patient b. Interaction with components of the environment c. The conceptual makeup of the administration of the hospital d. The illness and health concept e. Safety aspect of medication administration

Answers: a, b, d There are four components that a nursing theory discusses: (1) the patient, (2) health, (3) environment, and (4) nursing—not the hospital administration.

A nurse is working with a 35-year-old patient who needs to decide whether to donate a kidney to his brother who has been in renal failure for 5 years. The patient shares with the nurse that the decision is especially difficult because he would not be able to continue to work in his current profession and would be unable to support his three small children if he ever needed dialysis. Which intervention(s) would be most appropriate for the nurse to implement in this situation? (Select all that apply.) a. Explain that it is unlikely that he will ever need dialysis even if he has only one kidney. b. Guide the patient through a values clarification process to help him make a decision based on his values. c. Provide information the patient needs to help him make an informed decision. d. Ask for his permission to contact the kidney donation team to answer any questions he may have.

Answers: b, c, d Encouraging the patient to make a decision based on his personal values, providing necessary information, and offering consultation with individuals most familiar with the kidney donation process are all excellent interventions. It would be impossible to predict whether a patient will need dialysis in the future, making this type of statement misleading.

Which step(s) can nurses and health care providers take to remove barriers to identifying and treating victims of domestic violence? (Select all that apply.) a. Call the police. b. Ask about abuse. c. Ask for proof of domestic violence. d. Screen for domestic violence with all patients. e. Disregard reported abuse in spouses.

Answers: b, d Screening for domestic violence with all patients and asking about abuse will help identify patients who may be victims. Calling the police is a step that may be taken when abuse is confirmed but is not a step in identifying victims. Taking this step will be decided on with the involvement of both health care providers and the patient. Asking for proof may cause the victim to mistrust the health care provider. Never disregard a report of abuse. Abusers often are related to or married to the victim.

A new nurse is about to insert a nasogastric tube for the first time but is not sure what equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who is frightened and slightly confused. Which actions by the nurse would best demonstrate caring? (Select all that apply.) a. Offer the patient pain medication to help her calm down. b. Hold the patient's hand while inserting the nasogastric tube. c. Speak calmly while explaining the procedure to the patient beforehand. d. Ask another, more experienced nurse for assistance before initiating care.

Answers: c, d Using a calm voice and seeking help from an experienced nurse exhibit caring for the patient and will help to allay patient anxiety. Medicating a patient for pain before the experience will not automatically alleviate patient anxiety and may cause the patient to experience greater confusion. The nurse will need to use both hands to safely insert the nasogastric tube and promote a positive patient outcome, so the nurse is unable to hold the patient's hand during the procedure.

A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

B

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? 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."

B

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis. B. Ensuring that health care providers comply with regulations. C. Setting quality standards for accreditation of health care facilities. D. Determining if medications are safe for administration to clients.

B

A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select to prepare meals. C. Encourage the client to fill out an evaluation form. D. Ask the client if she has resources for further instruction on this topic.

B

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique. B. The client is able to demonstrate the appropriate technique. C. The client states that he understands. D. The client is able to write the steps on a piece of paper.

B

A nurse is reviewing car sear safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include? A. Use a car seat that has a three-point harness system. B. Position the car seat so that the infant is rear-facing. C. Secure the car seat in the front passenger seat of the vehicle. D. Convert to a booster seat after 12 months.

B

A nurse is talking with a parent who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as the priority? A. "My son mimics my husband getting dressed." B. "My son has temper tantrums every time we tell him to do something he doesn't want to do." C. "I think my son truly believes that his toys have personalities and talk to him." D. "I feel bad when I see my son trying so hard to button his shirt."

B

A nurse manager of a medical-surgical unit is assigned care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Change nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)

B

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply). A. The roommate ambulates independently. B. The client ambulates with his slippers on over his anti embolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of his breakfast this morning.

B C D

The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruit and vegetables. Which of the following responses should the nurse make? (Select all that apply). A. "It might be good to add bananas, as they can help with loose stools." B. "Let's make a list of the foods he is eating so we can spot any problems." C. "Did the changes begin after you started one particular food?" D. "Has he been vomiting since he started these new foods?" E. "Most babies react with a little indigestion when you start new foods."

B C D

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply). A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

B C D E

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 developmental tasks? (Select all that apply). A. Develop an acceptance of diminished strength and increased dependence on others. B. Spend time focusing on improving job performances. C. Welcome opportunities to be creative and productive. D. Commit to finding friendship and companionship. E. Become involved with community issues and activities.

B C E

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply). A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances

B C E

A nurse is reviewing the Centers for Disease Control and Preventions' (CDC) immunization recommendations with the parents of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply). A. Haemophilus influenza type B. Varicella C. Polio D. Hepatitis B E. Seasonal influenza

B C E

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

B D E

A nurse is reviewing the 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

B D E

A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (Select all that apply). A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid

B E

What specific aspect of a profession does the development of theories provide? a. a. Altruism b. b. Body of knowledge c. c. Autonomy d. d. Accountability

B Theories establish a specific nursing body of knowledge that is unique to the discipline, which is one criterion of a profession.

A nurse on an orthopedic unit is reviewing data for a client who sustained trauma in a motor-vehicle crash. Which of the following values indicates the client is in a catabolic state (using protein faster than protein is being synthesized)? A. Serum albumin 3.5g/dL. B. Negative nitrogen balance. C. BMI of 18.5. D. Serum prealbumin 12 mg/dL.

B.

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Alert the American Nurses Association B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep

C

A nurse in a provider's office is collecting data from the mother of a 12-month-old infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic

C

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say."

C

A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? A. "I kind of like this boy in my class, but he doesn't like me back." B. "I want to hang out with the kids in the science club, but the jocks pick on them." C. "I am so fat, I skip meals to try to lose weight." D. "My dad wants me to be a lawyer like him, but I just want to dance."

C

A nurse is talking with the parent of a 4-year-old child who states that his child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? A. Offer the child a large snack before bedtime. B. Allow the child to watch an extra 30 min of TV in the evening. C. Have the child take an afternoon nap. D. Increase physical activity before bedtime.

C

A nurse is teaching the father of a 12-year-old boy about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae C. Enlargement of the testes and scrotum. D. Deepening of the voice.

C

A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer.

C

A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply). A. Building models B. Working with clay C. Filling and emptying containers D. Playing with blocks E. Looking at books

C D E

A nurse is providing teaching for an older adult client who has lost 4.5kg (9.9lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply). A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

C D E

In comparing the American Nurses Association (ANA) and the International Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA's definition and is indicative of a more global focus? a. Advocacy b. Health promotion c. Shaping health policy d. Prevention of illness

C The ICN's definition of nursing expands on the ANA's definition by providing for the concept of shaping health policy as a responsibility of nursing.

Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of nursing professional practice are they exhibiting? a. a. Autonomy b. b. Accountability c. c. Cultural competence d. d. Autocratic leadership

C The nurse and other health care workers are exhibiting cultural competence by being responsive to patients' health beliefs and practices that are influenced by the individual's culture.

A nurse in an nutritional clinic is calculating body mass index (BMI) for several clients. The nurse should recognize which of the following client BMIs as overweight? A. BMI of 24 B. BMI of 30 C. BMI of 27 D. BMI of 32

C.

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the inter professional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist

D

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? 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 on win 3 months." D. "I keep forgetting which medications I have taken during the day."

D

A nurse is evaluating teaching about nutrition with the parents of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? A. "She wants to eat as much as we do, but we're afraid she'll soon be overweight." 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."

D

A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. Identify goals the nurse and the client agree are reasonable. D. Determine what the client knows about stress incontinence.

D

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for 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.

D

What is an example of Nightingale's contributions to nursing? a. Graduated as the first trained U.S. nurse b. Practiced nursing in the Civil War c. Established the Red Cross d. Emphasized respect for patients' needs and rights

D Clara Barton practiced nursing in the Civil War and established the Red Cross. Linda Richards was the first U.S. trained nurse. Nightingale emphasized patients' needs and rights.

A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? (Select all that apply). A. Reassure the child an injection will not hurt. B. Mix oral medications in a large glass of milk. C. Offer the child choices when possible. D. Have the parents bring in a favorite toy from home. E. Engage the child in pretend play with a toy medical kit.

D E

An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question? A. Assisting a client who is 24-hr postoperative to use an incentive spirometer B. Collecting a clean-catch urine specimens from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler

D teaching is for the RN. PN are only to reinforce the teaching

the type of learning (cognitive, affective, psychomotor) that involves feelings, belief, and values. hearing words and responding verbally and nonverbally... ext. "takes places when a client learns about life changes necessary for managing diabetes mellitus and then discusses their feelings about it"

affective

the conduct of one person making another person fearful and apprehensive is which term

assault

the actual physical contact without the clients consent is which term

battery

the type of learning (cognitive, affective, psychomotor) that requires intellectual behaviors and focuses on thinking. aka knowledge, comprehension, application, analysis, evaluation "takes place when clients learn the manifestations of hypoglycemia and then can verbalize when to notify the provider"

cognitive

which health care (preventive, primary, secondary, tertiary, restorative, continuing) hold these examples: home health care, hospice, adult day care, assisted living, in-home respite care, palliative care

continuing

which health care (preventive, primary, secondary, tertiary, restorative, continuing) pertains this definition: focuses on long-term or chronic care needs over a period of time

continuing

person is confined or restrained against his will

false imprisonment

ranges of BMI healthy body weight - overweight - obesity -

healthy BMI : 18.5 - 24.9 overweight BMI : 25 - 29.9 obesity BMI : greater or equal to 30

negative nitrogen balance is

indicates protein is used at a greater rate than it is synthesized as a starvation or a catabolic state following injury or disease

which health care (preventive, primary, secondary, tertiary, restorative, continuing) hold these examples: office or clinic visits, community health centers, scheduled school or work center screenings

primary

which health care (preventive, primary, secondary, tertiary, restorative, continuing) pertains this definition: focuses on educating and equipping clients to reduce and control risk factors

primary

which health care (preventive, primary, secondary, tertiary, restorative, continuing) pertains this definition: focuses on health promotion and includes prenatal and well-baby care, family planning, nutrition counseling, disease control

primary

the type of learning (cognitive, affective, psychomotor) that gains skills that require mental and physical activity like perception, guided response, mechanism, adaptation, origination. "takes place when a client practices something on their own"

psychomotor

which health care (preventive, primary, secondary, tertiary, restorative, continuing) pertains this definition: intermediate follow-up care for restoring health and promoting self-care

restorative

the five rights of delegation

right task right circumstance right person right direction and communication right supervision and evaluation

which health care (preventive, primary, secondary, tertiary, restorative, continuing) hold these examples: hospital settings, diagnostic centers, emergent care centers

secondary

which health care (preventive, primary, secondary, tertiary, restorative, continuing) pertains this definition: diagnosis and treatment of acute illness and injury

secondary

which health care (preventive, primary, secondary, tertiary, restorative, continuing) hold these examples: intensive care, oncology centers, and burn centers

tertiary

which health care (preventive, primary, secondary, tertiary, restorative, continuing) pertains this definition: acute care, provision of specialized and highly technical care

tertiary

how long can you expect the newborn to keep hands in a closed position

until ~2 mon

by which month is the babies gross motor skills include: sits down from a standing position without assistance

12

by which month is the babies gross motor skills include: lift head off mattress when prone

2

by which month is the babies gross motor skills include: roll from back to side

4

Men mature in which of the correct numbering orders 1. pubic hair 2. voice deepening 3. axillary hair 4. increase testes and scrotum 5. downy hair on upper lip 6. rapid genitalia growth

4- increase testes and scrotum 1- pubic hair 6. rapid genitalia growth 3. axillary hair 5. downy hair on upper lip 2. voice deepening

by which month is the babies gross motor skills include: pulls to a standing position

9

Which of the following questions may help the nurse determine the mental health status of a patient? a. How often do you have trouble relaxing? How often do you feel nervous? Do you have thoughts of harming yourself? b. Do you exercise? Do you work out 3 times a week? c. Do you eat a low-calorie, high-fiber diet? d. Are you sexually active? Do you practice safe sex?

ANS: A Those questions will elicit information that may help determine the mental health status of the patient and the possible need for intervention by the nurse or another provider. Questions regarding exercise will elicit information about the patients's physical activity status. Questions about a low-calorie, high-fiber diet are incorrect as they will elicit nutritional status information about the patient. Sexually active questions focus on the sexual health of the patient.

Which of the following questions should be included in the health assessment of the young adult? (Select all that apply.) a. Have you attempted to harm yourself in the past or do you have plans to do so now? b. What is your salary range? c. Do you keep guns in your house? d. Do you wear your seat belt?

ANS: A, C, D These questions may help reveal potential risk factors to the young as national statistics indicate that motor vehicle accidents accounted for 31% of deaths among young adults followed by homicides at 14.2% and suicides at 12.3%. Salary range may not offer much in the realm of potential health risk.

A 14-year-old male is upset because he is shorter in stature and smaller in build than the other boys in his class. He is concerned about never growing. How should the nurse address his concern? a. Reassure him that everyone grows at his own rate. b. Reassure him that males often do not stop growing until they are 18-20 years old. c. Tell him that most males start their growth spurt around 9-14 years of age. d. Tell him to take in more protein in order to get his growth spurt started.

ANS: B In males, the adolescent growth spurt usually begins sometime between the ages of 10-16 years of age and often does not end until 18-20 years. Although everyone grows at his or her own rate, it does not specifically address this boy's concern. The remaining options provide inaccurate information.

A toddler's parent expresses frustration over trying to get her toddler to bed at night. She explains that she has "tried everything." When asked about a bedtime routine, the mother states she has established no set bedtime, she just waits until the child falls asleep in front of the TV. What is the best advice for the nurse to give the mother? a. Stop the television and just put the child to bed without ceremony. b. Establish a set bedtime with a quiet routine beforehand. c. Continue to allow the child to fall asleep in front of the TV. d. Put the child in time-out whenever he or she resists going to bed.

ANS: B Toddlers often benefit from a set routine at bedtime, which meets the need for comfort and security. The other options do not reinforce the comfort and security the toddler needs at this stage. Television viewing time should be limited during childhood.

Nurses are most likely to utilize which of the following theories or models in their leadership role? a. Maslow and Erikson b. Health Belief Model c. Lewin d. Von Bertalanffy

ANS: C The nurse will use Lewin's change theory most often in the leadership role. Maslow's hierarchy of needs, Erikson's developmental theory, and the Health Belief Model will be utilized most during patient care and education.

A newborn's mother is concerned about Sudden Infant Death Syndrome (SIDS). What would the nurse advise her is the best way to prevent SIDS? a. To breastfeed b. To allow the infant to sleep in her bed c. To place the infant prone to sleep d. To place the infant supine to sleep

ANS: D The best way to prevent SIDS is to place the infant on its back to sleep. Breastfeeding has not been shown as a link to prevention of SIDS. Sleeping in bed with adults has been linked to infant death in that the parent may inadvertently roll over on the infant. Additionally, soft pillows and bed linens can contribute to accidental suffocation in young infants. The prone position for sleeping has been linked to SIDS deaths.

When teaching the patient mechanical barriers for birth control, the nurse would include which method? a. Diaphragm b. Transdermal patch c. Hormone injection d. Oral contraceptives

Answer: a The diaphragm is the only mechanical barrier listed for birth control. Oral contraceptives are absorbed through the gastrointestinal tract, hormones in injections, and transdermal patches are absorbed systemically

In using the PLISSIT model, what is the first action initiated by the nurse? a. Present basic information about sexual functioning. b. Ask permission to begin the sexual assessment. c. Inquire about any medications the patient is taking. d. Ask the patient about sexual activity and practices.

Answer: b Before initiating discussion via the PLISSIT model, the nurse should first seek permission to have the conversation with the patient. All of the other listed steps occur, but only after permission is obtained.

A 2-year-old child insists on having a drink of water and having a story read to him and says "Good night, sleep tight" at bedtime every night. The nurse knows the child is exhibiting which type of behavior? a. Controlling b. Ritualism c. Obsession d. Compulsion

Answer: b Ritualism offers the toddler a sense of security and comfort. The child is not trying to control his behavior with the ritual. Obsession and compulsion are terms commonly used in patients in older age groups and describe maladaptive behaviors.

When teaching female reproduction to a group of high school students, the nurse uses what term to indicate the cessation of a woman's menstrual activity? a. Menarche b. Menopause c. Premenstrual syndrome d. Menstrual dysfunction

Answer: b The definition of menopause is the cessation of a female's menstrual activity. Menarche is the onset of menstruation. Premenstrual syndrome is a set of specific symptoms that occur before the monthly menstrual cycle. Menstrual dysfunction refers to altered patterns of menstruation associated with various disorders

How is the toddler's need for autonomy best met? a. The parents' consistently meeting the child's needs b. Allowing the child limited choices c. Encouraging imaginative play d. Promoting experimentation to determine cause and effect

Answer: b The toddler's need for autonomy can best be supported by allowing the child choices within limits. Parents consistently meet the child's needs during the infant period. In later developmental stages, imaginative play is encouraged, and experimentation is promoted to determine cause and effect.

A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the patient's chart. The nurse is performing which specific nursing function? a. a. Diagnosis b. b. Assessment c. c. Education d. d. Advocacy

Answer: b The nurse is performing the first step in the nursing process: assessment.

A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? A. "I should keep feeding my son whole milk until he is 3 years old." B. "It's okay for me to give my son a cup of apple juice with each meal." C. "I'll give my son about 2 tablespoons of each food at mealtimes." D. "My son loves popcorn, and I know it is better for him than sweets."

C

A nurse is talking with the parents of a 10-year-old child who is concerned that their son is becoming secretive, such as closing the door when he showers, and dresses. Which of the following responses should the nurse make? 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 the age, children tend to become modest and value their privacy." D. "You should establish a disciplinary plan to stop this behavior."

C

A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist

D

a client returning from surgery requires which nurse (PN, RN, CNA, AP, charge nurses) assessment to establish a plan of care

RN

by which month is the babies gross motor skills include: changes from prone to a sitting position

10

by which month is the babies gross motor skills include: cruises or walks while holding onto something. walks with one hand held

11