ATI: test 3

A. Turn the client's head to the side.

1. A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open. C. Brush the client's teeth once per day. D. inject a mouth rinse into the center of the client's mouth.

d. the client expresses concerns about the next generation.

1. 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.

C. Pressure ulcer

1. a nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? a. decreased subcutaneous fat b. Muscle atrophy C. Pressure ulcer d. Fecal impaction

D. Determine the client's ability to help with the transfer.

2. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. obtain a walker for the client to use to transfer back to bed. B. call for additional staff to assist with the transfer. c. Use a transfer belt and assist the client back into bed. D. Determine the client's ability to help with the transfer.

B. spend time focusing on improving job performance. C. Welcome opportunities to be creative and productive. e. Become involved with community issues and activities.

2. A nurse is collecting data to evaluate a middle adult's psychosocial development. the nurse should expect middle adults to demonstrate which of the following 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 performance. C. Welcome opportunities to be creative and productive. d. Commit to finding friendship and companionship. e. Become involved with community issues and activities.

A. Building models B. Playing video games c. reading books

2. A nurse is planning diversionary activities for school‑age children on an inpatient 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

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."

2. A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) 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."

A. Influenza C. Pertussis d. tetanus

2. A nurse is reviewing CdC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch‑up, during young adulthood? (select all that apply.) A. Influenza B. Measles, mumps, rubella C. Pertussis d. tetanus e. Polio

A. suggest that his parents bring in video games for him to play. B. Provide a television and dVds for the adolescent to watch. d. Involve the adolescent in treatment decisions when possible. e. Allow the adolescent to perform his own morning care.

2. 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. Hypotension

2. a nurse educator is presenting a module on basic first aid for newly licensed home health nurses. the nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? a. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

B. affective

2. 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

B. "i will go to the nurses' station for assistance."

2. a nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? a. "i will place the client on his side." B. "i will go to the nurses' station for assistance." C. "i will administer his medications." D. "i will prepare to insert an airway."

C. devoting a great deal of time to establishing an occupation

3. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse should include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. devoting a great deal of time to establishing an occupation d. Finding oneself "sandwiched" between and being responsible for two generations

A. Metabolism C. Gastric secretions e. Glomerular filtration

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

c. sit on the side of her bed and rest her arms over pillows on top of her bedside table.

3. A nurse is completing discharge instructions for a client who has coPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. lie on her back with her head and shoulders on a pillow. B. lie flat on her stomach with her head to one side. c. sit on the side of her bed and rest her arms over pillows on top of her bedside table. D. lie on her side with her weight on her hip and shoulder with her arm flexed in front of her.

d. "We reward her school achievements with a point system instead of a pizza or ice cream."

3. 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."

B. Varicella d. Human papilloma virus e. seasonal influenza

3. 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

A. Face

4. A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

c. "I am so fat, I skip meals to try to lose weight."

4. 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."

a. sleeps 14 to 16 hr each day D. Hands remain in a closed position e. Current weight same as birth weight

4. a nurse is assessing from a 2‑week‑old newborn during a routine checkup. Which of the following findings should the nurse expect? a. sleeps 14 to 16 hr each day B. Posterior fontanel closed C. Pincer grasp present D. Hands remain in a closed position e. Current weight same as birth weight

a. Complete a fall‑risk assessment.

4. a nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? a. Complete a fall‑risk assessment. B. educate the client and family about fall risks. C. eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in his possession.

b. "this thing will keep the blood pumping through my leg."

4. a nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? a. "this device will keep me from getting sores on my skin." b. "this thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." d. "this device is going to keep my joints in good shape."

B. Brush the dentures with a toothbrush and denture cleaner.

5. A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them

D. an older adult who is postoperative following a below‑the‑knee amputation

5. a charge nurse is assigning rooms for the clients to be admitted to the unit. to prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? a. a middle adult who is postoperative following a laparoscopic cholecystectomy B. a middle adult who requires telemetry for a possible myocardial infarction C. a young adult who is postoperative following an open reduction internal fixation of the ankle D. an older adult who is postoperative following a below‑the‑knee amputation

B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products. e. Handling raw and fresh food separately can prevent food poisoning

5. a home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) a. most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products. D. Healthy individuals usually recover from the illness in a few weeks. e. Handling raw and fresh food separately can prevent food poisoning

B. ask the client to explain how to select or prepare meals.

5. 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 or 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. "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?"

5. 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 fruits 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."

Ch 24

Ch 24

B. semi‑Fowler's

1. A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. supine B. semi‑Fowler's C. semi‑prone D. Trendelenburg

d. "I keep forgetting which medications I have taken during the day."

1. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my son to help around the house." C. "I just heard my friend Al died. that's the third one in 3 months." d. "I keep forgetting which medications I have taken during the day."

A. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping."

1. 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."

B. "It is important to schedule routine health care visits even if I am feeling well."

1. A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "I will just go to an urgent care center for my routine medical care." d. "there's no reason to seek help if I am feeling stressed because it's just part of life."

c. enlargement of the testes and scrotum

1. 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. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. e. Complete a fall‑risk assessment.

1. a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) a. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. e. Complete a fall‑risk assessment.

c. a client who has partial‑thickness and full‑thickness burns to his face, neck, and chest

1. a nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? a. a client who received crush injuries to the chest and abdomen and is expected to die B. a client who has a 4‑inch laceration to the head c. a client who has partial‑thickness and full‑thickness burns to his face, neck, and chest d. a client who has a fractured fibula and tibia

a. store toxic agents in locked cabinets. C. Turn pot handles toward the back of the stove. d. Place safety gates across stairways.

1. 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.

B. the client is able to demonstrate the appropriate technique.

1. 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. Nail polish should not be used near a client who is receiving oxygen. C. a "No Smoking" sign should be placed on the front door. e. a fire extinguisher should be readily available in the home.

1. a nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) a. family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. a "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. e. a fire extinguisher should be readily available in the home.

c. have the child take an afternoon nap.

1. 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.

a. rolls from back to front B. Bears weight on legs D. sits unsupported e. sits down from a standing position

1. 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. inspect the feet daily. B. Use moisturizing lotion on the feet. e. Wear cotton socks.

2. A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. inspect the feet daily. B. Use moisturizing lotion on the feet. C. Wash the feet with warm water and let them air dry. D. Use over‑the‑counter products to treat abrasions. e. Wear cotton socks.

B. Place blankets over clients who are confined to beds. c. Move beds away from the windows. d. draw shades and close drapes.

2. a nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) a. Open doors to client rooms. B. Place blankets over clients who are confined to beds. c. Move beds away from the windows. d. draw shades and close drapes. e. instruct ambulatory clients in the hallways to return to their rooms.

b. apply elastic stockings. E. assist the client to change position often.

2. a nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) a. instruct the client not to perform the Valsalva maneuver. b. apply elastic stockings. C. Review laboratory values for total protein level. d. Place pillows under the client's knees and lower extremities. E. assist the client to change position often.

a. "My baby loved to play with his crib gym, but I took it away from him."

2. 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. assembling puzzles c. Using musical toys D. Playing with puppets e. coloring with crayons

2. 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

C. Filling and emptying containers d. Playing with blocks e. looking at books

2. 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

B. Pneumococcal immunization C. Yearly eye examination d. Periodic mental health screening e. Annual fecal occult blood test

3. 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

A. Schedule rest periods during morning care.

3. A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client.

D. "once my infant starts to push up, I will remove the mobile from over the crib."

3. a nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? a. "I will set my water heater at 130° f." B. "once my baby can sit up, he should be safe in the bathtub." C. "I will place my baby on his stomach to sleep." D. "once my infant starts to push up, I will remove the mobile from over the crib."

a. Encourage the client to perform antiembolic exercises every 2 hr.

3. a nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?? a. Encourage the client to perform antiembolic exercises every 2 hr. b. instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. d. Reposition the client every 4 hr.

D. have the parents bring in a favorite toy from home. e. engage the child in pretend play with a toy medical kit.

3. 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.

C. "Can you tell me about how long the surgery will take?"

3. 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."

B. Position the car seat so that the infant is rear‑facing.

3. a nurse is reviewing car seat 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.

a. establish consistent boundaries for the toddler.

3. 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.

C. Move clients who are nearby.

3. a nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? a. extinguish the fire. B. activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

c. Brush the chemical off the skin and clothing.

3. an occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. irrigate the affected area with running water. B. Wash the affected area with antibacterial soap. c. Brush the chemical off the skin and clothing. d. leave the clothing in place until emergency personnel arrive.

C. "I don't even know who I am yet, and now I'm supposed to know what to do."

4. A nurse is counseling a young adult 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 have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." d. "My girlfriend is pregnant, and I don't think I have what it takes to be a good father."

A. eye examination every 1 to 3 years C. dXA screening for osteoporosis d. increase intake of carbohydrate in the diet e. screening for depressive disorders

4. 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. Increase protein intake to increase muscle mass. C. Increase calcium intake to prevent osteoporosis. d. limit sodium intake to prevent edema. e. Increase fiber intake to prevent constipation.

4. A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (select all that apply.) A. Increase 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.

c. "At this age, children tend to become modest and value their privacy."

4. 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 this age, children tend to become modest and value their privacy." d. "You should establish a disciplinary plan to stop this behavior."

A. request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. D. Use smooth movements when lifting and moving clients.

4. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (select all that apply.) A. request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. c. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.

D. Carbon monoxide binds with hemoglobin in the body.

4. a home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? a. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. the lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.

a. Trying to increase her independence

4. 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

d. determine what the client knows about stress incontinence.

4. 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.

B. Varicella c. Polio e. seasonal influenza

4. a nurse is reviewing the centers for Disease control and Prevention's (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 influenzae type B B. Varicella c. Polio D. hepatitis a e. seasonal influenza

d. "i will listen for background noises."

4. a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? a. "i will get the caller off the phone as soon as possible so i can alert the staff." B. "i will begin evacuating clients using the elevators." c. "i will not ask any questions and just let the caller talk." d. "i will listen for background noises."

B. "The lower my center of gravity, the more stability i have." c. "To broaden my base of support, i should spread my feet apart." D. "When i lift an object, i should hold it as close to my body as possible."

5. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (select all that apply.) A. "my line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability i have." c. "To broaden my base of support, i should spread my feet apart." D. "When i lift an object, i should hold it as close to my body as possible." E. "When pulling an object, i should move my front foot forward."

B. decreased height d. nail thickening e. decreased bladder capacit

5. A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (select all that apply.) A. skin thickening B. decreased height C. Increased saliva production d. nail thickening e. decreased bladder capacit

B. "it's been so stressful for me to think about having intimate relationships."

5. 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."

A. Provide information about the risk of childhood obesity. B. discuss the danger of substance use disorders. c. Promote discussion about sexual issues. e. reinforce stranger awareness.

5. 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. 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.

5. 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.

B. Wear a helmet while skiing. C. Install a carbon monoxide detector. d. secure firearms in a safe location.

5. A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. d. secure firearms in a safe location. e. remove throw rugs from the home.

a. Hold the cane on the right side. b. Keep two points of support on the floor. d. after advancing the cane, move the weaker leg forward.

5. a nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) a. Hold the cane on the right side. b. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. d. after advancing the cane, move the weaker leg forward. E. advance the stronger leg so that it aligns evenly with the cane.

C. "I'll give my son about 2 tablespoons of each food at mealtimes."

5. 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."

B. "My son has temper tantrums every time we tell him to do something he doesn't want to do."

5. 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."

c. a client who is scheduled for elective surgery d. a client who has chronic hypertension and blood pressure 135/85 mm Hg

5. a nurse on a medical‑surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) a. a client who is dehydrated and receiving iV fluid and electrolytes B. a client who has a nasogastric tube to treat a small bowel obstruction c. a client who is scheduled for elective surgery d. a client who has chronic hypertension and blood pressure 135/85 mm Hg e. a client who has acute appendicitis and is scheduled for an appendectomy

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