Health Promotion and Maintenance 2
The nursing staff at the pediatric hospital discuss instituting a community education program regarding intellectual disabilities, particularly prevention. It is most beneficial for the nurses to emphasize which area? 1. Alcoholism treatment. 2. Phenylketonuria (PKU) screening. 3. Nutritional supplementation. 4. Prenatal classes.
1 (1) CORRECT - Alcohol is recognized as the leading cause of preventable intellectual disability. This is included in the fetal alcohol syndrome (FAS) complex of symptoms. 2) INCORRECT - Screening for PKU occurs in newborns as a routine part of their care. 3) INCORRECT - Nutrition supplementation is important, especially considering the absence of folic acid is a teratogen causing spina bifida. However, many foods are now supplemented to offset this risk. Therefore, preventing or reducing alcohol-related birth defects is a priority that is best addressed in a community program. 4) INCORRECT - Prenatal classes tend to focus on the parents in the last trimester of pregnancy, when any issues with the fetus may be already developed and no longer preventable or reversible. )
The nurse provides care for a client who is 18 weeks pregnant with twins. The client has a child who was born at 30 weeks' gestation and has had two spontaneous abortions previously. Which does the nurse document for the client's GTPAL? 1. G-4, T-0, P-1, A-2, L-1. 2. G-5, T-0, P-2, A-2, L-2. 3. G-4, T-1, P-2, A-2, L-2. 4. G-5, T-1, P-1, A-2, L-1.
1 (1) CORRECT - The GTPAL status is calculated as follows: gravida-4 (twins count as 1 parous experience); term-0 (client carried no child to term, which is the beginning of 38th week to the end of the 42nd week); para, or preterm delivery-1 (child born at 30 weeks); abortion-2 (spontaneous and elective abortions); living-1 (1 living child at home). 2) INCORRECT - This is an incorrect interpretation. 3) INCORRECT - This is an incorrect interpretation. 4) INCORRECT - This is an incorrect interpretation.)
A client is diagnosed with heart failure (HF). Which information will the nurse include when teaching the client about self-management at home? (Select all that apply.) 1. Take medications at the same time each day. 2. Limit the consumption of sodium to 3 to 4 grams per day. 3. Avoid non-steroidal anti-inflammatory agents (NSAIDs). 4. Report increased shortness of breath to the health care provider. 5. Inform the health care provider about a weight gain greater than 3 lb/week.
1, 3, 4, 5 (1) CORRECT- Medication adherence is critical in preventing HF exacerbation. 2) INCORRECT - Sodium intake is limited to less than 2 grams a day for clients with HF. 3) CORRECT- It is known that NSAIDs cause sodium and fluid retention, so they are best avoided. 4) CORRECT- The nurse should encourage clients to be proactive in reporting increased symptoms of HF, including shortness of breath. 5) CORRECT- A weight gain greater than 3 lb/week signifies fluid retention.)
The nurse performs a physical assessment on an older adult client. Which findings does the nurse expect for this client? (Select all that apply.) 1. The client has increased flexibility. 2. The client 's height has decreased by 1 inch. 3. The client can perform full range of motion. 4. The client has increased endurance. 5. The client has diminished muscle tone. 6. The client has joint stiffness.
2, 5, 6 (1) INCORRECT — A client will have decreased flexibility due progressive deterioration of cartilage with advanced age in most women. 2) CORRECT— The decrease in height is caused by decreased bone density in the vertebrae. 3) INCORRECT — An older adult client has diminished range of motion due to progressive deterioration of cartilage. 4) INCORRECT — Most older adult clients have decreased endurance due to the atrophy of muscles. 5) CORRECT— The tone is decreased due to the diminished size of muscles. 6) CORRECT— The stiffness is due to changes in the cartilage.)
A parent brings a 10-month-old child to the health clinic. The parent asks the nurse when the child will be ready to begin toilet training. Which response by the nurse is accurate? 1. "Your child is ready now." 2. "Your child will be ready in 2 months." 3. "Your child should be ready in another 8 to 12 months." 4. "Your child will tell you when your child is ready."
3 (1) INCORRECT - Toilet training should begin when the child is able to achieve voluntary control over the urinary sphincter. This is not achieved until 18 to 24 months of age. It is too early to begin at 10 months. 2) INCORRECT - Twelve months of age is too early to begin toilet training. 3) CORRECT - Voluntary control over sphincters is achieved at 18 to 24 months. 4) INCORRECT - Parents may recognize a child's readiness. A toddler may be curious about a parent's toilet habits, but is unlikely to reliably indicate their own readiness.)
The nurse is teaching a group of clients about vasectomies and tubal ligations. Which information does the nurse include in the teaching? 1. A tubal ligation is medically less complicated than a vasectomy. 2. Menstruation ceases after a tubal ligation. 3. Birth control measures are required after a vasectomyuntil the client has a negative sperm count. 4. A vasectomy is performed as a laparoscopic surgery.
3 (1) INCORRECT- Vasectomy is considered the easiest and most commonly used operation for male sterilization, and is less complicated than a tubal ligation. 2) INCORRECT- The menstrual period will be about the same as it was before the sterilization. The tubal ligation impacts the ability of an egg to migrate to the uterus. It does not impact the lining of the uterus or hormonal regulation of the uterine lining. 3) CORRECT- It may take approximately 3 months for the client to achieve a negative sperm count in seminal fluid analysis after a vasectomy. Alternative methods of birth control should be used during this period. 4) INCORRECT- Two methods are used for scrotal entry. Those include conventional and non-scalpel vasectomy. Neither are considered a laparoscopic procedure.)
The nurse instructs a group of parents about age-appropriate toys for toddlers. Which toys will the nurse recommend that toddlers use? (Select all that apply.) 1. Educational computer programs. 2. Play clothes for dress-up. 3. Pounding board. 4. Cloth picture books. 5. Tricycle. 6. Skates.
3, 4 (1) INCORRECT - Educational computer programs are appropriate for preschoolers, not toddlers. 2) INCORRECT - Play clothes for dress-up are appropriate for preschoolers, not toddlers. 3) CORRECT - A pounding board is an appropriate toy for the toddler, as it promotes physical activity. 4) CORRECT - Cloth picture books are an appropriate toy for toddlers, as they stimulate mental development and creativity. 5) INCORRECT - A tricycle is appropriate for preschoolers, not toddlers. 6) INCORRECT - Skates are appropriate for preschoolers, not toddlers.)
The nurse prepares to complete an assessment of cranial nerves IX and X. Which supplies will the nurse obtain to complete the assessment? 1. A cotton ball. 2. A tuning fork. 3. An ophthalmoscope and Snellen-like chart. 4. A tongue depressor and flashlight.
4 ( To test these nerves, the nurse will need something to touch the back of the client's throat, such as a tongue depressor, and a flashlight to watch the uvula rise in the back of the throat when swallowing. 1) INCORRECT - Cranial nerves IX and X control the pharynx and gag reflex. A cotton ball is not needed. 2) INCORRECT - A tuning fork might be used to assess cranial nerve VIII, not IX and X. 3) INCORRECT - An ophthalmoscope and Snellen-like chart are used to assess cranial nerve II, not cranial nerves IX and X. 4) CORRECT— Cranial nerves IX and X are the glossopharyngeal and vagus nerves, which control the client's ability to swallow and the gag reflex. A tongue depressor and flashlight are needed. )
The nurse screens clients for the risk for developing pulmonary tuberculosis (TB). Which client is at risk for developing this type of TB? 1. Client with cystic fibrosis. 2. Client with chronic obstructive pulmonary disease. 3. Client who has a tuberculin (Mantoux) test site that has a 4 mm area of induration. 4. Client with positive test results for the human immunodeficiency virus.
4 (1) INCORRECT - Cystic fibrosis is not a risk factor for TB. 2) INCORRECT - Chronic obstructive pulmonary disease is not a risk factor for TB. 3) INCORRECT - A tuberculin (Mantoux) test site that has a 4 mm area of induration is negative for TB. 4) CORRECT - The client who is positive for the human immunodeficiency virus can be immunocompromised. The TB organism is opportunistic. This client is at a high risk for developing active TB.)
The nurse makes a prenatal visit to the home of a client who is pregnant with a first child. Which observation would be of most concern to the nurse? 1. A cat is sleeping peacefully on the windowsill. 2. Cleaning supplies are in an unlocked cabinet under the kitchen sink. 3. There are throw rugs on the living room floor. 4. The smoke detector is chirping intermittently.
1 (1) CORRECT — A cat presents a toxoplasmosis risk to the pregnant client and her unborn fetus. Toxoplasmosis is a parasitic disease transmitted in the feces of cats that have eaten infected mice and animals. Preventive measures include handwashing after touching cats and having the litter box changed daily (it takes about 1 to 5 days for the cat's feces to become infectious) by someone other than the pregnant person. Prevent cats from eating raw meat or wild animals. Wear gloves when gardening, and do not garden in areas frequented by cats. Avoid undercooked meat and contact with stray animals. 2) INCORRECT — This will be an issue for future teaching, prior to the yet-unborn infant becoming a toddler. 3) INCORRECT — Although the rugs could be a falling hazard for the client, the priority is information regarding the cat. 4) INCORRECT — The chirping smoke detector indicates that a battery needs changing or that the unit is defective. This is important but not the priority.)
The nurse discusses health care with a client diagnosed with polycystic ovary syndrome (PCOS). Which information is important for the nurse to include? 1. Maintain a normal weight. 2. Increase calcium and phosphorus intake. 3. Avoid exposure to the sun. 4. Eliminate alcohol from the diet.
1 (1) CORRECT — It is important to teach the client the importance of weight management and exercise to decrease insulin resistance. Obesity exacerbates the problems related to PCOS. Losing weight may help hormones reach normal levels, lower blood glucose levels, and improve the way the body uses insulin. A 10% loss in body weight may result in a more regular menstrual cycle and an improved chance of becoming pregnant. An example of a 10% weight loss would be if a 150 lb (68.2 kg) woman lost 15 lb (6.8 kg). 2) INCORRECT — Increasing calcium and phosphorus intake has no relationship to PCOS. 3) INCORRECT — Avoiding exposure to the sun has no relationship to PCOS. 4) INCORRECT — Eliminating all alcohol from the diet has no relationship to PCOS. )
The nurse provides care for a pregnant client. The client comes for a second prenatal visit at 15 weeks' gestation. The client's blood pressure is 120/72 mm Hg. The client's first blood pressure at 12 weeks' gestation was 124/80 mm Hg. Which action does the nurse implement based on this information? 1. Document the blood pressure. 2. Retake the blood pressure with the client in a side-lying position. 3. Review nutrition with the client to determine iron intake. 4. Notify the health care provider.
1 (1) CORRECT- The client's systolic blood pressure usually remains the same as the pre-pregnancy level, but may decrease slightly as the pregnancy advances. Both of these values are within normal limits. Therefore, the nurse documents the blood pressure. 2) INCORRECT - The blood pressure should be taken with the arm in the horizontal position at heart level. This is not an appropriate action. 3) INCORRECT - There is no indication that the client is anemic or lacks iron. This is not an appropriate intervention. 4) INCORRECT - There is no need to notify the health care provider. Both blood pressures are within normal limits. )
The nurse provides care for a 12-month-old client during a wellness visit. The client is due to receive the first dose of the measles, mumps, and rubella (MMR) vaccine. The nurse notes that the client has a low-grade fever and signs of a minor respiratory illness. Which action by the nurse is appropriate? 1. Administer the vaccine on schedule. 2. Postpone the vaccination until the child becomes afebrile. 3. Postpone the vaccination until the respiratory illness is gone. 4. Administer an antipyretic and then administer the vaccine.
1 (1) CORRECT—The child should receive the vaccine as scheduled. Vaccination should not be postponed because of low-grade fever or minor respiratory illness. 2) INCORRECT - The child should receive the vaccine as scheduled. Vaccination should not be postponed because of low-grade fever or minor respiratory illness. 3) INCORRECT - The child should receive the vaccine as scheduled. Vaccination should not be postponed because of low- grade fever or minor respiratory illness. 4) INCORRECT - An antipyretic is not indicated for treatment of a low-grade fever.)
The nurse presents information to staff regarding anatomic changes that occur shortly after birth to facilitate a newborn's adaptation to extrauterine life. Which anatomic changes are included by the nurse in the teaching session? (Select all that apply.) 1. Decrease in pulmonary vascular resistance. 2. Closure of the foramen ovale. 3. Closure of the ductus arteriosus. 4. Decrease pressure in the left atrium. 5. Closure of the ductus venosus.
1, 2, 3, 5 (1) CORRECT - As blood flows through the lungs and fetal shunts close, increased blood flow dilates pulmonary vessels. This change occurs to maintain blood pressure. 2) CORRECT - This circulatory system change occurs at or soon after birth, as the result of pressure changes in the lungs, heart, and major vessels. 3) CORRECT - This circulatory system change occurs by the fourth day as the result of pressure changes in the lungs, heart, and major vessels. 4) INCORRECT - There is an increase, not a decrease, in pressure in the left atrium. 5) CORRECT - This circulatory system change occurs as the result of pressure changes in the lungs, heart, and major vessels.)
The nurse provides care for a client in the first trimester of pregnancy. The client experiences nausea. Which information does the nurse provide to the client? (Select all that apply.) 1. Nausea may be linked to the mother 's acceptance of the pregnancy. 2. Nausea should diminish by the 14th week of pregnancy. 3. Eating a dry carbohydrate immediately upon arising is recommended. 4. Decreasing the intake of protein in the evening meal may help. 5. Avoid fried, spicy, and greasy foods.
1, 2, 3, 5 (1) CORRECT- Ambivalence about, or rejection of, the pregnant state may cause nausea. 2) CORRECT - Nausea begins about 4 weeks after the last menstrual period, and usually improves by the end of the 14th week of pregnancy. Nausea is associated with an increase of human chorionic gonadotropin (hCG) levels in early pregnancy. 3) CORRECT - Eating a dry carbohydrate upon waking up in the morning may help decrease nausea. 4) INCORRECT - Eating more protein at night may help with nausea. 5) CORRECT - Avoiding fried, spicy, and greasy foods can help. )
The nurse assesses a 10-year-old client during a well-child visit. Which statements will the nurse expect the client to make? (Select all that apply.) 1. "I am allergic to strawberries. Whenever I eat one my lips get real big." 2. "I have a kitten. I love having an animal." 3. "This is my sword!" while holding a pen. 4. "A child in my class has hurt feelings when teased by others." 5. "I would love to have an extra eye on my hand, so I could see around corners with it!"
1, 2, 4 (1) CORRECT - According to Piaget's concrete operational stage, inductive logic is appropriate at this age. 2) CORRECT - According to Piaget's concrete operational stage, reversibility thinking is appropriate at this age. 3) INCORRECT - This is appropriate for Piaget's pre-operational stage, which occurs before the client reaches the age of 10. 4) CORRECT - According to Piaget's concrete operational stage, children should be able to take on the perspective of others. 5) INCORRECT - This is appropriate for Piaget's formal operational stage, which occurs before the client reaches the age of 10.)
The nurse teaches staff members about developmental considerations related to bowel elimination. Which statements are appropriate for the nurse to include in the teaching? (Select all that apply.) 1. "An infant 's stool will vary depending on how the infant is fed. " 2. "Bowel control is usually achieved before bladder control. " 3. "Voluntary control of anal and urethral sphincters begins at about 30 months of age. " 4. "Constipation in the older adult can be related to decreased gastrointestinal motility. " 5. "Fecal impaction may be associated with oozing of liquid feces. "
1, 2, 4, 5 (1) CORRECT - The formula-fed infant excretes pale yellow to light brown stools. They are firmer in consistency than those of the breastfed infant. The stools of infants fed with breastmilk are seedy, and the color and consistency of mustard with a sweet-sour smell. 2) CORRECT - Bowel control is usually achieved before bladder control. 3) INCORRECT - Voluntary control of anal and urethral sphincters begins at about 18 to 24 months 4) CORRECT - Older adults may experience slowed peristalsis related to the loss of muscle elasticity, reduced intestinal mucous secretion, or a low-fiber diet. 5) CORRECT - The cardinal sign of impaction is continuous oozing of liquid stool, with no normal stool. Oozing occurs as the liquid portion of feces higher in the intestines seeps around the mass. )
The nurse provides care to a toddler-age client who has a laceration to the left hand. Which actions by the child require investigation by the nurse? (Select all that apply.) 1. Persistently disobeys the parent after instructions to sit down. 2. Explores items found within the exam room. 3. Continues to scream after having the hand wrapped with gauze. 4. Hides behind the parent during interactions with the nurse. 5. Smiles when receiving a sticker after the treatment.
1, 3, 4 (1) CORRECT - Disobeying the parent indicates defiance and is a negative outcome of development. 2) INCORRECT- Exploring is a positive developmental outcome and is expected for a client of this age. 3) CORRECT - Screaming after receiving treatment indicates fearful behavior and is a negative outcome of development. 4) CORRECT - Hiding behind a parent indicates withdrawal and is a negative outcome of development. 5) INCORRECT - Smiling when receiving a sticker after treatment is a positive developmental outcome.)
The nurse teaches an adult female client with a family history of hypertension. Which recommendation does the nurse include in client education? (Select all that apply.) 1. Limit sodium intake to 2 grams or less daily. 2. Exercise at least twice weekly. 3. Avoid use of tobacco products. 4. Limit alcohol consumption to one serving per day. 5. Limit coffee consumption to two servings daily.
1, 3, 4 (1) CORRECT - Excessive sodium intake (greater than 2 grams daily) increases the risk for hypertension. 2) INCORRECT - A sedentary lifestyle increases the risk for hypertension. The American Heart Association recommends moderate activity for at least 30 minutes daily, 5 days per week. 3) CORRECT - Smoking or the use of other tobacco products increases the risk for hypertension. 4) CORRECT - Excessive alcohol intake is linked to hypertension. For adult females, no more than one serving of alcohol per day is recommended. 5) INCORRECT - Although caffeine may cause a spike (not a sustained increase) in the blood pressure of some people, coffee use is not a recognized risk factor for hypertension.)
An older adult client asks the nurse about the appropriate exercise necessary to maintain optimal musculoskeletal function. Which information does the nurse include in the response to the client? 1. Weight-bearing exercise is not recommended for older adults. 2. High-intensity resistance training can improve muscle strength in older adults. 3. Muscle deterioration in older adults is expected. 4. Walking is the only healthy exercise for older adults.
2 ( Step-By-Step Walkthrough 1) INCORRECT - This type of exercise helps prevent osteoporosis. 2) CORRECT - This activity, along with walking and social activity, can significantly improve the health of older adults. 3) INCORRECT - This response does not address the question adequately. Although muscle mass and elasticity begin to diminish from the aging process, exercise programs that include walking or weight-bearing activities can help maintain optimal function. 4) INCORRECT - Weight-bearing exercises and other forms of physical activity are beneficial for older adults. )
The nurse provides care for an adult client diagnosed with uterine cancer who is receiving chemotherapy. Which statement indicates to the nurse that the client has a realistic perception of the health status? 1. "I will be cured after my therapy is complete." 2. "I have started buying scarves of different colors." 3. "I will be carrying a full load of classes this semester." 4. "I must have done something to cause this illness."
2 (1) INCORRECT - A cure may or may not happen. 2) CORRECT— This indicates that the client is realistic about what may happen because of chemotherapy. The client should be encouraged to obtains wig, scarves, or hats before losing hair. 3) INCORRECT - This is not a realistic perspective. Weakness and fatigue are common side effects of chemotherapy. 4) INCORRECT - This indicates blame and guilt, not a realistic perspective. )
The nurse provides care for a client who gave birth 1 day ago via cesarean section. The client experiences difficulty breastfeeding due to incisional pain. Which action is most appropriate for the nurse to take? 1. The nurse feeds the newborn until the client is more comfortable. 2. Have the client attempt different breastfeeding positions for comfort. 3. Have the client breastfeed the baby and offer prescribed pain medication when the client is done nursing. 4. Offer the client a breast pump so the client can bottle feed the baby.
2 (1) INCORRECT - Having the nurse feed the newborn until the mother is more comfortable could prevent an adequate milk supply on the part of the mother. 2) CORRECT- Mothers who gave birth by cesarean often prefer the football or clutch hold to avoid stress on the incision. Before discharge from the birth institution, the nurse should help the mother try different positions so that the mother will be confident in trying these positions at home. 3) INCORRECT - If pain medication is used, it can be given before nursing. Anti-inflammatory medications, such as ibuprofen, can help reduce the pain and swelling associated with engorgement. 4) INCORRECT - Trying different positions for breastfeeding should be attempted prior to turning to pumping and then bottlefeeding.)
The nurse provides care for a client who is human immunodeficiency virus (HIV) positive and has been taking anti-retroviral therapy (ART) for 15 years. Which health maintenance activity does the nurse teach this client related to the adverse effects of long term ART? 1. "Obtain an annual flu immunization." 2. "Have your lipid profile checked." 3. "Use a latex condom during sex." 4. "Monitor your viral load periodically."
2 (1) INCORRECT - Immunization for the flu is appropriate for general health. It is not related to the adverse effects of long-term ART. 2) CORRECT- Long-term ART leads to hyperlipidemia and cardiovascular disease, possibly due to chronic stress. 3) INCORRECT - Using condoms prevents HIV transmission. It is not relevant to the adverse effects of ART. 4) INCORRECT - Monitoring the viral load is irrelevant to the adverse effects of ART. The viral load test measures the amount of HIV RNA in the blood. )
The nurse presents a teaching session to a postpartum client who just delivered her first newborn. When educating the client about breastfeeding, which action does the nurse implement? 1. Instruct the client to use an antiseptic soap to cleanse her breasts. 2. Remain with the client and newborn during the breastfeeding. 3. Inform the client that the newborn will require breastfeeding 4-6 times per day. 4. Advise the client to use only the cradle position when breastfeeding.
2 (1) INCORRECT - The client should be instructed to use plain water when cleansing her breasts, as soap may cause drying and cracking of the skin, nipples, and areolae. 2) CORRECT— The nurse should remain with the client to assess effectiveness of the newborn's suck, swallow, and gag reflex. Observation of the breastfeeding sessions offers an excellent opportunity to evaluate effectiveness of the feeding and provide additional teaching. 3) INCORRECT - Newborns typically require feeding 8-12 times each day. 4) INCORRECT - A variety of positions may be used to facilitate breastfeeding. Classic positions include cradle position, modified cradle position, side-lying position, and football (or clutch) hold position.)
The nurse provides care for a young adult female client diagnosed with type 1 diabetes mellitus (DM). When teaching the client about measures to prevent long-term complications, which instruction does the nurse include? 1. "Use a vaginal douche after each menstrual period." 2. "Wear cotton undergarments." 3. "Limit your fluid intake to 2 liters per day." 4. "Empty your bladder every 6 hours."
2 (1) INCORRECT— Using a vaginal douche increases the risk of vaginal infections, especially yeast infections. Female clients with diabetes are at higher risk for vaginal infections due to the altered glucose metabolism. The nurse will instruct the client to avoid the use of vaginal douches. 2) CORRECT — The nurse will encourage the client to wear undergarments made of natural fibers, such as cotton, which are more breathable than synthetic fibers. Cotton undergarments tend to absorb moisture more effectively than other materials and allow air to circulate better, decreasing the risk of vaginal infection. 3) INCORRECT— The female client with diabetes should be encouraged to drink plenty of fluids. Staying hydrated will flush the urinary tract on a regular basis and decrease the risk of urinary tract infection. The client with diabetes is at higher risk for urinary tract infection and should take measures to reduce that risk, including adequate fluid intake. 4) INCORRECT— The client with DM is at higher risk for urinary tract infection. Delayed emptying of the bladder results in urine stasis and increased risk of infection. The nurse will instruct the client to frequently empty the bladder to reduce the risk of infection.)
The nurse develops a teaching plan for a pregnant client. A goal of the plan is to promote cardiac output during pregnancy. Which instruction is most important for the nurse to tell the client? 1. "Take frequent rest periods." 2. "Modify your regular aerobic exercise as pregnancy progresses." 3. "Lie on your left side when sleeping or resting." 4. "Elevate feet whenever sitting."
3 (1) INCORRECT - Although important information, taking frequent rest periods does not improve cardiac output. 2) INCORRECT - Although important information, this does not improve cardiac output. 3) CORRECT- In the supine position, particularly during the second half of pregnancy, the weight of the gravid (pregnant) uterus partially occludes the vena cava and the aorta. This reduces cardiac output and can lead to the development of supine hypotensive syndrome. Lying on left side takes the weight of the uterus off the vena cava and increases blood return to the heart, which will promote cardiac output. 4) INCORRECT - Elevating the feet can decrease peripheral edema and may assist in improving blood return to the heart, but it is not as important as having the pregnant patient lie on the side.)
The nurse provides care for a 7-year-old client during a wellness examination. Which factor in the child's history alerts the nurse that hyperlipidemia screening is necessary? 1. Maternal history of obesity. 2. Paternal history of diabetes mellitus. 3. Sibling history of stroke. 4. Grandparent history of hypertension.
3 (1) INCORRECT - Hyperlipidemia screening is warranted in this age group if the child, not the mother, has a history of obesity. 2) INCORRECT - Hyperlipidemia screening is recommended if the child in this age group has diabetes mellitus, not a parent. 3) CORRECT - If the child has a sibling with a history of stroke, screening for hyperlipidemia is recommended in children ages 2 to 8 years. 4) INCORRECT - Hyperlipidemia screening is recommended for a child diagnosed with hypertension. It is not warranted if the child's grandparents have a history of hypertension.)
The nurse conducts a quality assurance review of a laboring client's health record. Which entry does the nurse reviewer bring to the attention of the nurse manager? 1. 1035: Five minutes after epidural initiated, client's blood pressure is 80/48 mm Hg. Client positioned left side down. 2. 1050: Fetal heart rate is 90 to 100 beats/min after epidural block. O 2 by face mask administered to client at 10 L/min. 3. 0820: 500 mL IV fluid bolus of Lactated Ringer's solution completed. 1030: Anesthesiologist present to begin administration of epidural block. 4. 1102: Fetal heart rate sustained at 100 beats/min for more than 10 minutes. Lactated Ringer's solution infusion rate increased to wide open per protocol.
3 (1) INCORRECT - Maternal hypotension causes a decrease in placental perfusion. Positioning the client on the left side is appropriate, as this position increases placental perfusion. 2) INCORRECT - A sustained fetal heart rate of less than 110 beats/min is considered bradycardia. Administration of oxygen to the client is indicated in the event of fetal bradycardia. 3) CORRECT— Epidural blockade produces vasodilation and typically causes a decrease in blood pressure. Administration of an IV fluid bolus prior to an epidural block is intended to offset potential hypotension by increasing the fluid volume in the intravascular space. To optimize the effects of the fluid bolus, the IV fluid should be administered over 20-30 minutes and the epidural procedure begun shortly thereafter. 4) INCORRECT - A sustained fetal heart rate of less than 110 beats/min is considered bradycardia. Administration of IV fluid (without any medication) as prescribed or per protocol is an appropriate intervention for fetal bradycardia. )
The nurse provides care for four newborn clients. Which client does the nurse assess first? 1. The newborn who is 6 hours old and has a blue-black discoloration on the right buttock. 2. The newborn who is 10 hours old and has not passed meconium. 3. The newborn who has not voided since having a circumcision 7 hours ago. 4. The newborn who is having the first formula feeding and has not been screened for phenylketonuria (PKU).
3 (1) INCORRECT - Mongolian spots, which are bluish discolorations of the skin, are common in infants of African American, Native American, and Mediterranean descent. They are usually found over the sacral and gluteal areas. They disappear spontaneously during the early years of life. 2) INCORRECT - Meconium, the first stool of the newborn, may be passed anytime within 12 to 24 hours. 3) CORRECT - Noting the first urination after circumcision is important because edema could cause an obstruction. If the infant goes home before voiding, the mother is instructed to call the health care provider if there is no urinary output within 6 to 8 hours. 4) INCORRECT - A test for PKU is mandatory in all states. If the infant has this disorder, a special formula begun in the first 2 months of life can reduce intellectual disability in most cases. The PKU test is done on the day of discharge for better accuracy, and it is repeated during early clinic visits.)
The nurse provides care for a client at 28 weeks' gestation. The nurse counsels the client about how to prepare her 2-year-old child for the new baby. Which statement made by the client indicates that further teaching is necessary? 1. "I am going to wait another month to tell my child about the new baby." 2. "I have given my child a baby doll, bottles, and diapers." 3. "I am talking to my child about being a big sibling." 4. "We are already getting my child used to sleeping in a bed rather than the crib."
3 (1) INCORRECT - This is an appropriate action. Toddlers have a vague or unclear conception of time. It is often a good time to discuss the arrival of a new baby when the toddler becomes aware of the pregnancy and the home-related preparations. This may be several weeks before the birth or somewhat sooner. 2) INCORRECT - This is an appropriate action. This gives the toddler familiarity with an infant, especially if not previously exposed to one. It also provides the opportunity to imitate parental behaviors, such as feeding and diapering. 3) CORRECT — This is not age-appropriate. A toddler is too young to understand and focus on the big sister/big brother concept. Explaining this concept would be more appropriate for preschoolers. 4) INCORRECT - This is an appropriate action. It avoids or minimizes what could otherwise be a major change to which the child must adjust once the infant arrives (moving from crib to bed and/or changing rooms). This should be done well in advance of the new baby's birth. )
An older adult client has a medical history that includes hypertension. A public health nurse visits this client regularly. Which finding does the nurse expect for this client? 1. Temperature 99.5°F (37.5°C), pulse 110 beats/min, respirations 32 breaths/min, blood pressure 140/80 mm Hg. 2. Temperature 98.6°F (37°C), pulse 78 beats/min, respirations 16 breaths/min, blood pressure 120/80 mm Hg. 3. Temperature 99.8°F (37.7°C), pulse 90 beats/min, respirations 20 breaths/min, blood pressure 150/90 mm Hg. 4. Temperature 96.8°F (36°C), pulse 80 beats/min, respirations 20 breaths/min, blood pressure 160/90 mm Hg.
4 (1) INCORRECT - The temperature, pulse, and respirations are too high for the older adult client. These are not expected findings. 2) INCORRECT - The nurse would not expect completely normal vital signs for this client. 3) INCORRECT - The temperature and pulse are elevated. The nurse would not expect these findings. 4) CORRECT - The temperature is usually lower in the older adult client due to a decrease in the basal metabolic rate. The BP is expected with a history of hypertension, particularly since there is no indication the client is being controlled with an antihypertensive.)
The nurse watches as a parent and infant interact. The infant throws a toy to the floor numerous times. The parent picks up the toy and gives it back to the infant. If the parent does not immediately return the toy, the infant cries loudly. Which statement by the nurse is best? 1. "Be sure to wipe the toy off each time before you give it back. These floors are filthy." 2. "Your baby is either stubborn or wants attention, I cannot figure out which." 3. "I remember when my own baby used to do that." 4. "I bet your baby is about 11 months old. This is normal behavior."
4 (1) INCORRECT— This is a valid concern, but the statement is patronizing and does not acknowledge the parent's feelings. It also implies that the parent is not intelligent enough to recognize dirty floors or take care of the baby's health. 2) INCORRECT — This statement may encourage discussion, but it implies judgment, especially since no relationship has yet developed between nurse and parent. It also implies incorrect information. This is normal behavior for an 11-month old and does not indicate a desire for attention or stubbornness. 3) INCORRECT — This response focuses on the nurse. The nurse should address the parent's concerns. 4) CORRECT— At 11 months, an infant drops an object deliberately in order that it can be picked up. Even if the infant is not 11 months, equating a problematic behavior with a developmental norm can help decrease the parent's probable sense of aloneness, inadequacy, embarrassment, and frustration. )