Collaborative-Health Promotion and Maintenance

Apply pressure to her back during contractions.

A laboring client reports low back pain. What should a nurse recommend to the client's coach that will promote comfort?

A male client with cystic fibrosis becomes romantically involved with a woman with the same disorder. He asks the nurse about the chances of having an affected child like himself. How should the nurse respond?

A male client with cystic fibrosis becomes romantically involved with a woman with the same disorder. He asks the nurse about the chances of having an affected child like himself. How should the nurse respond?

Discontinue the oxytocin infusion.

A client in labor is receiving an oxytocin (Pitocin) infusion. What should the nurse do first when repetitive late decelerations of the fetal heart rate are observed?

Prevent loss of calcium from long bones."

A client that has been immobilized for an extended period of time questions why the tilt table is being used. The nurse's best response is, "The tilt table is used to help:

Preserve muscle strength

A client with scleroderma is scheduled to begin a regimen of daily exercises. The nurse explains that the purpose of the exercises is to:

Reducing environmental stimuli to promote relaxation

A newborn is found to have neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care?

Modeling appropriate behaviors that encourage infant bonding

A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks on the phone to her friends and does not respond when her new baby cries. What is the best immediate intervention?

Crown-to-rump measurement until 11 weeks

A nurse is caring for a client during an ultrasonogram. What parameters does the nurse expect to be used in the determination of pregnancy dates?

Remaining in bed as prescribed

A nurse is implementing a teaching plan for a pregnant client who is noncompliant with maintaining bedrest. What is the most appropriate short-term goal?

contact from their parents

A nurse is observing hospitalized toddlers in the playroom. What does the nurse identify as their most important need?

Hypertension

A nurse is performing a physical assessment of a pregnant woman. What factor in the client's history increases the risk for abruptio placentae?

Onlooker play

A child watches an older sibling playing with a ball, but makes no effort to participate in the play. What social character of play is the child exhibiting?

Allowing the client and family members to voice feelings, myths, and fantasies about ECT

A client and the client's spouse are presented with electroconvulsive therapy (ECT) as a treatment option instead of pharmacotherapy after the client experiences adverse effects of medication therapy. The nurse meets with them to discuss the procedure. What should the nurse's first action be?

Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? Select all that apply

Focus on and repeat a rhythmic chant. Eat small, frequent meals and eat dry crackers in between.

A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea, but no vomiting, throughout the day. What should the nurse recommend? Select all that apply.

"Have you considered the option of genetic counseling?"

A client has a child with Tay-Sachs disease and wants to become pregnant again. She tells the nurse, "I'm worried it will happen again." How should the nurse respond?

The possible need for prophylactic antibiotic therapy before dental work

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?

Immediate passive short term immunity

A construction worker sustains a puncture from a rusty nail. It is unknown when the worker had the last immunization for tetanus and the primary health care provider prescribes tetanus immune globulin. What protection does this type of immunization offer?

Transition

A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client reports that she is going to vomit. What phase of the first stage of labor does the nurse suspect the client has entered?

Swelling of the soft tissue of the scalp as a result of pressure during labor

A nurse is assessing a newborn with caput succedaneum. What does the nurse tell the mother is the cause of this fetal condition?

Fecal occult blood testing should be performed yearly beginning at age 50 years.

A nurse is planning a community health program about screening for cancer. Which information recommended by the American Cancer Society (ACS) should the nurse include?

Difficulty inserting the irrigation tube

A nurse is providing discharge teaching for a client who recently had surgery for an abdominal perineal resection of the colon and the creation of a colostomy. The nurse instructs the client to notify the primary health care provider immediately if, during a colostomy irrigation, the client experiences:

When one sperm penetrates the wall of the ovum

A nurse is teaching a class about childbearing and contraceptive options. The nurse explains that fertilization of the ovum by the sperm occurs at a specific time. When does it occur?

Large versus small

A nurse is teaching a class for staff members working in a group home about the cognitive development of children with cognitive impairments. What concept can these children probably learn the fastest?

It should remain in place for at least 6 hours after intercourse to be effective.

A nurse is teaching a female client how to use a diaphragm to prevent pregnancy. What information should the nurse include?

Being shy with strangers Showing interest in small objects

A nurse is teaching a parent about the behaviors that are first evident in an infant at 8 months of age. What should the nurse include? Select all that apply.

Presenting information on how smoking affects appearance and odor of the breath

A nurse on the adolescent unit is planning to discuss smoking prevention. What is the most effective approach for the nurse to use?

Watching cartoon videos and listening to stories

A nurse on the pediatric unit is planning recreational activities for a 4-year-old with an exacerbation of nephrotic syndrome. What are the most appropriate activities, in light of the child's developmental level and physical status?

preterm

A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified?

Father heterozygous (sickle trait), mother heterozygous (sickle trait)

A nurse who works in a fertility clinic is discussing the inheritance pattern of sickle cell disease with the parents of a school-aged child with the disease. The parents are planning to have a second child. The nurse knows that the parental genotypic makeup is:

Lack the subcutaneous fat that usually provides insulation

A parent of a preterm infant asks a nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they:

Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

A postpartum client intends to breastfeed her infant for the first time. How should the nurse assist the client?

"I'm glad I'll be able to get back into my jogging routine next week."

The nurse is conducting teaching for a client being discharged after an abdominal hysterectomy. Which statement by the client indicates a need for further teaching?

Feelings of immortality in the child are undesirable and should be condemned.

The nurse is counseling the parents of an adolescent child on the benefits of social development in the child's maturation process. Which statement by the nurse needs correction to convey an appropriate message to the parents?

Shredded wheat cereal.

The nurse is developing a list of appropriate foods for a client who has been prescribed a low sodium diet. The nurse reviews the list with the client. The nurse evaluates that the teaching is understood when the client states, "It is okay for me to eat:

The lengthwise growth of the neck and extremities occurs before growth in other areas of the body. This is followed by an increase in the breadth of the hips and chest. Months later there is an increase in shoulder width. Then the trunk increases in length. Finally there is an increase in the depth of the chest. This sequential growth pattern results in the characteristic gawky, long-legged appearance of early adolescence.

The nurse is examining a teenage patient who has a gawky, long-legged appearance. What is the sequence of growth changes that lead to this characteristic early adolescent appearance?

Increase my lean body mass

The nurse provides education related to the relationship between aerobic exercise and weight loss to an obese client. The nurse evaluates that this teaching is effective when the client states, "I know that exercise will:

"The American Academy of Pediatrics recommends the intramuscular vaccine because it is safer."

The parents of an infant ask the nurse why their baby is scheduled to receive the intramuscular polio vaccine rather than the oral vaccine. What is the best response by the nurse?

The disorder consists of right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta.

The parents of an infant with tetralogy of Fallot ask a nurse about the problems involved with this disorder. When answering, what must the nurse consider?

Temporary passive acquired immunity

An 11-year-old boy who has stepped on a rusty nail is given tetanus immune globulin in the emergency department. The nurse knows that the immune globulin injection will confer:

Inactivated poliovirus

An 18-month-old child has received all required immunizations. What immunization should the nurse explain to a parent will be one of the vaccines required between 4 and 6 years of age?

Talk softly and cuddle the baby when crying occurs.

An adolescent who gave birth one day ago confides to the nurse that she hopes that her baby will be good and sleep through the night. What should the nurse include in the plan of care to facilitate a realistic expectation of a nighttime newborn schedule?

Suckling stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex

Before teaching a client about breastfeeding, what should the nurse consider about hormonal influences?

Three vessels: one vein and two arteries

During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn?

By initiating therapeutic play

How can a nurse teach a preschooler about medical interventions most effectively?

Documenting an intact reflex

In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?

"I should secure pulse oximeter probes with elasticized dressing material."

The registered nurse is teaching a student nurse about adhesives to be used for preterm infants. Which statement by the student nurse indicates effective learning?

Promote effective pushing by the client

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

Reversible separation

What concept of death should a nurse expect a 4-year-old child to have?

Late beginning of childbearing

What factor identified by the nurse in a client's history places the client at increased risk for breast cancer?

Blood loss of 850 mL after a vaginal birth

What information in a postpartum client's health history should alert the nurse to monitor the client for signs of infection?

The child believes God will punish bad behavior and reward good behavior.

When assessing the development of a school-age child, the nurse concludes that the child has normal development according to Fowler's spiritual development theory. Which behavior helped the nurse reach this conclusion?

Apply cool packs to her breasts to reduce the discomfort. Take the analgesic medication prescribed to limit the discomfort. Assume a different position when breastfeeding to adjust the infant's sucking.

A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? Select all that apply.

Stop smoking

A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD). What is the most beneficial lifestyle modification the nurse should teach this client?

Take thyroid replacement medications as prescribed.

A client is being discharged after having a total thyroidectomy. Which instruction would be most important for the nurse to include?

Lacerations are easier to repair than an episiotomy.

A client tells a nurse that she does not want an episiotomy and would rather tear naturally. What information should be offered regarding each of these birthing methods?

Allow the child to play with a syringe, using a doll, before treatment is initiated and after each injection is administered.

A 3-year-old child with chronic lead poisoning who has not responded to succimer (Chemet) therapy must be given multiple injections of edetate calcium disodium (calcium EDTA). How should the nurse prepare the child psychologically for this treatment?

"How much caffeine do you consume each day?"

A 40-year-old client states, "I feel like my heart is jumping out of my chest, and it is skipping beats." The client passes a thallium stress test; however, the health care provider identifies one premature ventricular complex (PVC) and several premature atrial complexes (PACs) on the 24-hour follow-up Holter monitor. Which question is most important for the nurse to ask the client?

Cooperative

A 5-year-old child is brought to the child health clinic for a routine visit, and the nurse observes the child interacting with other children. What type of play does the nurse expect of the child?

Assisting the new mother with breastfeeding Taking and recording weight and height Placing the infant under a warmer and attaching a sensor probe Performing a head-to-toe physical examination Giving erythromycin eye ointment and a vitamin K shot

A newborn was delivered 25 minutes earlier. Once identification bands have been applied and vital signs have been taken, what interventions does the nurse need to complete? Place these actions in the order of their priority.

Generativity versus stagnation

According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to the developmental stage of:

Assessment of skin turgor Administration of antiemetic drugs Replacement of fluid and electrolytes

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply.

Assess her breastfeeding techniques to identify possible causes.

On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information?

Longer-lasting active immunity

The mother of a 17-year-old adolescent who is going to be a foreign exchange student asks the nurse why her child must have a tetanus toxoid immunization instead of tetanus immunoglobulin. The nurse responds that the tetanus toxoid immunization provides:

The child is at increased risk for dental caries.

The mother of a 2-year-old child expresses concern to the nurse in the pediatric clinic that her child still takes a bottle of milk to bed at night. How should the nurse explain to the mother that this practice should be stopped?

Peripheral vasoconstriction

The nurse encourages a client with Raynaud's disease to stop smoking because it causes:

Metrorrhagia Ovarian cancer Bowel strictures Voiding difficulties

The nurse is obtaining a health history from a client with endometriosis. What consequences can occur as a result of this disorder? Select all that apply.

Middle adolescence

The nurse is teaching hygiene practices to a 16-year-old patient who has recently had her first menstrual flow. Under which phase of development does the nurse classify the patient?

Open glottis

What breathing technique does the nurse instruct a pregnant woman to use as the fetus's head crowns on the perineum?

The child is unable to feed himself. The child is unable to climb the stairs.

Which behavior of a 3-year-old child indicates delayed development? Select all that apply.

Wooden puzzle with large pieces

Which is the most appropriate toy for a nurse to offer a 2½-year-old child?

Crackers or Zwieback

Which solid food can be given to a 6-month-old infant?

Pounding toy Play telephone Box filled with plastic figures

Which toys should the nurse identify as most appropriate for a 3-year-old child? Select all that apply.

Climb stairs with two feet on each step.

While conducting an assessment of a child's development, what does a nurse expect a 24-month-old toddler to be able to do?

A paper bag

While performing shallow, rapid breathing during transition, a client in labor experiences tingling and numbness of her fingertips. The nurse encourages her to breathe into:

Kegel

A pregnant couple is attending preparation-for-childbirth classes. Which exercise should the nurse teach the mother to increase the tone of the muscles of the pelvic floor

Samples of no-salt-added diets for the child to continue at home

A 6-year-old child treated for acute glomerulonephritis has improved and is soon to be discharged. What should the nurse plan to offer the parents in preparation for the discharge?

The procedure is uncomfortable, but there should not be a damaging long-term effect.

A 7-month-old girl is to be catheterized so a sterile urine specimen may be obtained. One of the infant's parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance?

Highly active sebaceous glands in "flush areas" of the body

The nurse is applying skin ointment to acne lesions on a patient who has recently reached puberty. What does the nurse anticipate as the cause for the extensive acne?