Health Promotion and Maintenance

Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which of the following would be the best response by the nurse?

A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made. "Hypertension is confirmed by three readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. Nurses are not to provide false hope to clients; hypertension is more prevalent in women who do not menstruate; no information was given about this."

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents?

Arrange a meeting between the health care team and the parents to develop a care plan. "A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge."

A client who is 16 weeks pregnant reports many mood swings. Which statement accurately describes estrogen and progesterone levels during this client's stage of pregnancy?

Both estrogen and progesterone levels are rising. "Until the seventh month of pregnancy, estrogen and progesterone are secreted in progressively greater amounts. Between the seventh and ninth months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio contributes to mood swings."

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include?

Client will verbalize the intention to stop smoking. "A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina)."

A nurse is assessing the chest of a 4-month-old infant. The nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:2. Which actions should the nurse take next?

Document the findings in the client's medical record. "This is a normal finding and requires no further action. As this is a normal finding, a chest X-ray is unnecessary. All the other responses suggest a respiratory disorder and that further evaluation is needed."

The nurse is assessing a client with hepatitis A and notices that the aspartate transaminase (AST) and alanine transaminase (ALT) lab values have increased. Which statement by the client indicates the need for further instruction by the nurse?

I take acetaminophen for arthritis pain. "Acetaminophen is toxic to the liver and should be avoided in a client with liver dysfunction. Increased periods of rest allow for liver regeneration. A low-fat, high-carbohydrate diet and dry toast to relieve nausea are appropriate."

A nurse asks a pregnant client about her alcohol use. The client admits she sometimes has several glasses of wine with dinner. Her alcohol consumption puts her fetus at risk for which condition?

Learning disability "Maternal alcohol use during pregnancy may cause fetal and neonatal central nervous system deficits such as learning disabilities. It also may lead to characteristic physical anomalies and growth restriction. Maternal alcohol use doesn't cause alcohol addiction in the fetus or neonate. Anencephaly occurs when the cranial end of the neural tube fails to fuse before the 26th day of gestation; this condition isn't related to maternal alcohol use. Down syndrome results from a chromosomal disorder."

Which statement by a parent reflects the need for further teaching regarding car seat safety?

My baby should stay in a rear-facing car seat until he is 1 year old "New guidelines recommend that parents keep their toddlers in a rear-facing car seat until 2 years of age or they reach maximum height and weight for the seat. Car seats are marked with an expiration date because the integrity of the plastic may deteriorate with age. Booster seats are recommended for older children until they are 4 feet 9 inches (144.8 cm). This typically occurs between the ages 8 and 12 years. Children should ride in the back seat until they are 13 years of age to minimize injury should airbags be deployed."

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the pharynx. "To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the pharynx with a tongue blade, which should elicit gagging. Having the client say "ah" allows the nurse to evaluate cranial nerves IX and X. However, the nurse needn't use a tongue blade to hold down the tongue; the client need only stick out their tongue. Placing a tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client."

The mother of a toddler tells the nurse her son bites other children. What should the nurse advise the mother to do?

Place the child in "time-out." "Biting is an unacceptable aggressive behavior that should not be allowed. Placing the child who did the biting in time-out is most appropriate because it removes the child from the situation and the other children and also teaches the child that the behavior is inappropriate. The toddler should be removed from the situation; talking to the child will not help the child learn that the behavior is not appropriate. Spanking the child is inappropriate because doing so reinforces the hitting behavior as appropriate. Biting is a common behavior in toddlers and can be managed by the parents unless the child does not respond to being placed in "time-out"; it is not necessary to refer the mother to a child psychologist at this time."

The nurse is educating a client on diabetes management. The client is asking questions that cause the nurse to be concerned about the client's ability to retain the information. Which would be the best technique for the nurse to use to enhance the retention of information by the client?

Repeat important information during the presentation. "Repetition is an effective means of reinforcing critical information and enhancing content retention. The other options will not increase the client's ability to retain information and may decrease the client's concentration and ability to retain critical information."

A mother approaches the nurse to discuss which childbirth education classes she should take. Which one of the following responses would be the most appropriate initial response from the nurse?

What do you want to learn about? "To be client centered, the nurse needs to determine what this mother's learning needs are. Other barriers that exist, such as finances and access to classes, should be part of the nurse's role to work with the parent to overcome as part of working to full scope of practice. This would not be the first question asked, however."

Risk factors for the development of breast cancer include:

early onset of menstruation. "A woman's lifetime exposure to estrogen is implicated in breast cancer development. Therefore, early onset of menstruation, delayed onset of menopause, and childlessness or delayed childbearing all appear to increase a woman's risk of breast cancer. A family history of the disease also appears to increase a woman's risk. Menstruation is delayed until breastfeeding ceases, which limits a woman's exposure to estrogen. Therefore, breastfeeding may reduce, not increase, risk."

A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy?

warning signs of complications "In early childbirth education classes, instruction on the physiologic aspects of pregnancy may include warning signs of complications, the anatomy and physiology of pregnancy, nutrition, and fetal development. Signs and symptoms of labor, quickening and fetal movements, and false and true labor are usually discussed in later classes."

The nurse is providing health screening for adolescent girls. Which of the following adolescent girls does the nurse identify as highest risk for an unplanned pregnancy? Select all that apply.

- an adolescent girl living in poverty - an adolescent girl with low self-esteem - an adolescent girl with low educational achievement - an adolescent girl dating an older boy "Young women may try to use a pregnancy to escape a poor living situation. Those with low education and literacy levels may not possess the knowledge or information needed to protect themselves from unwanted pregnancies. A young woman with low self-esteem may be pressured into a sexual relationship, especially when involved with an older boy, resulting in an unwanted pregnancy."

An adolescent primigravid client at 26 weeks' gestation has gained 25 lb (11.34 kg) since becoming pregnant. Which of the following is the recommended amount of weight gain during the third trimester?

1 lb (0.45 kg) per week "The pattern of weight gain is commonly more important than the amount. Clients should be advised to gain a total of 25 to 35 lb (11.34 to 15.88 kg) if they are of average weight when becoming pregnant. The recommended pattern is 1 lb (0.45 kg) per month in the first trimester, then 1 lb (0.45 kg) per week in the second and third trimesters. A sudden increase in weight gain is associated with pregnancy-induced hypertension, whereas a sudden weight loss may indicate an illness."

A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem?

pain "During transition, contractions are increasing in frequency, duration, and intensity. The most appropriate nursing problem is pain related to strength and duration of the contractions. Insufficient information is provided in the scenario to support the other listed nursing diagnoses. Urinary retention would be appropriate if the client had a full bladder and was unable to void. Hyperventilation might apply if client was breathing too rapidly, but there is no evidence this is occurring. Ineffective coping might apply if the client said, "I can't do this" or something similar."

During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action?

reddened tympanic membrane without discomfort "To perform an otoscopic examination on an adult, the nurse grasps the auricle of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the auricle and pulls it down to straighten the ear canal. Normal findings should include visualization of the ossicles through the tympanic membrane, fine hairs in the auditory canal with wax, and reflection of light off the light-gray or pearly white shiny ear drum. A reddened ear drum would indicate an infection with our without pain."

A nurse is teaching a male client to perform monthly testicular self-examinations. Which point is appropriate to make?

Testicular cancer is a highly curable type of cancer. "Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger, not older, men."

A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer.

- "Take off the cap and shake the inhaler." - "Attach the spacer." - "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." - "Press down on the inhaler once and breathe in slowly." - "Hold your breath for at least 10 seconds, then breathe in and out slowly." - "Rinse your mouth."

A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of:

how well the neonate tolerated labor. "Apgar scores, given at 1 and at 5 minutes after birth, indicate how well the neonate tolerated labor and how well he made the transition to extrauterine life. These scores also provide the foundation for additional nursing interventions, if needed. Apgar scores aren't used to determine the gestational age of the neonate."

A nurse is assigned to care for a non-English-speaking client. Which is the most appropriate action by the nurse to provide effective nursing care?

request a trained interpreter "The nurse assigned to care for a non-English speaking client should request a trained interpreter. Communicating with gestures and symbols may not give accurate and detailed information. Taking help from a bilingual family member is not advisable because interpretation of behavior goes beyond translation of words. Much medical vocabulary and terminology is difficult to translate into other languages. Should the client's condition deteriorate, the emotional burden of responsibility could be overwhelming for someone close to the client. Requesting help from colleagues is not feasible."

A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit?

Edema "At each prenatal visit, the nurse should assess the client for edema because edema, increased blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic measurements and Rh typing are determined at the first visit only because they don't change. The nurse should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation."

A graduate nurse is asking for information about chronic renal failure. Which statement by the nurse would be most accurate when providing teaching?

It is characterized by azotemia, fluid volume excess, and hyperkalemia. "When chronic renal failure occurs, the body is unable to eliminate the wastes, resulting in azotemia. In addition, the kidneys are not able to eliminate the body fluids, resulting in fluid volume overload. There is also a rise in potassium levels resulting in hyperkalemia. The most common cause of chronic renal failure is diabetes. There is a depression of erythropoietin with chronic renal failure. The liver converts wastes to creatinine and blood urea nitrogen, not the kidneys."

The nurse is preparing to discharge a client with asthma. Which intervention is most important for the nurse to perform prior to discharge?

Obtain additional equipment and medication that can be provided at the school "The child needs to have equipment and medication available at school to treat and prevent asthma attacks. A discussion should be held with the child and family to motivate the child to be involved in as many normal childhood activities as possible. The house should be kept as clean as possible to prevent exacerbations due to dust and pet dander. If the child is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks."

A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. What should the nurse instruct the mother to do?

Tell the nurse when the neonate voids. "The nurse should instruct the mother to report the first voiding after the circumcision because edema could cause a urinary obstruction. Although reading a pamphlet about circumcision care may be helpful, it may not be appropriate for all mothers. Some mothers could have difficulty reading or understanding the information. Petroleum jelly gauze is used with Gomco clamp circumcisions, not Plastibell. Petroleum jelly should not be used with Plastibell circumcision methods because the bell prevents further bleeding."

The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which would most likely contribute to the achievement of this goal?

administering famotidine as ordered "Clients with burns are susceptible to the development of Curling's ulcer, a gastroduodenal ulcer that is caused by a generalized stress response. The stress response results in increased gastric acid secretion and a decreased production of mucus. Prevention is the best treatment, and clients are frequently treated prophylactically with antacids and H2 histamine blockers such as famotidine."

A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which factor?

an immature cardiac sphincter "Initial regurgitation in the neonate during the first 12 to 24 hours may be caused by excessive mucus and gastric irritation from foreign substances in the stomach. After the first 24 hours, regurgitation is thought to be caused by the neonate's immature cardiac sphincter. It represents an overflow of stomach contents and is probably a result of feeding the neonate too fast or too much. A defect in the gastrointestinal system usually results in more severe symptoms. A small amount of regurgitation is normal, but vomiting or forceful fluid expulsion is not. Burping the infant often during a feeding can decrease the amount of air in the stomach from swallowing. However, burping too often can lead the neonate to become tired or fussy. Moving the infant usually does not result in regurgitation."

A nurse is proving anticipatory guidance to the family of a school-age child with acute lymphocytic leukemia. Which recommendation should the nurse make?

being treated as "normal" as much as possible "Any child with a chronic illness should be treated as normally as possible. Unless the child has severe bone marrow depression, he should be allowed to go to school with others and can go to the mall. If the child is in remission, athletic activities are allowed."

A multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Based on these findings, the nurse should recognize that the client is in which phase of labor?

transitional phase "The transitional phase of labor occurs as the cervix dilates from 8 to 10 cm; it's the shortest but most difficult and intense phase for the client. The latent phase occurs as the cervix dilates from 0 to 3 cm; this phase is mild in nature. The active phase occurs as the cervix dilates from 4 to 7 cm; this phase is moderate for the client. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta."

The parent of a 9-month-old expressed concern that the baby "is developing slowly." The nurse is concerned about a developmental delay when finding the baby is unable to accomplish which skill?

vocalizing single syllables "Normally, a 9-month-old infant should have been voicing single syllables since 6 months of age. Absence of this finding would be a cause for concern. An infant usually is able to stand alone at about 10 months of age. An infant usually is able to build a tower of two cubes at about 15 months of age. An infant usually is able to drink from a cup with little spilling at about 15 months of age."

The nurse is teaching a new prenatal client about her iron-deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia?

I may have anemia because my family is of Asian descent. "Iron-deficiency anemia is caused by insufficient iron stores in the body, poor iron content in the diet of the pregnant woman, or both. Other thalassemias and sickle-cell anemia, rather than iron-deficiency anemia, can be associated with ethnicity but occur primarily in clients of African or Mediterranean origin. Because red blood cells increase by about 50% during pregnancy, many clients will need to take supplemental iron to avoid iron-deficiency anemia. A pregnant client is considered anemic when the hemoglobin is below 11 mg/dl (110 g/l). In most types of anemia, the heart must pump more often and harder to deliver oxygen to cells."

When instructing a client about the proper use of condoms for pregnancy prevention, the nurse should include which instructions to ensure maximum effectiveness?

Place the condom over the erect penis before coitus. "To ensure maximum effectiveness, the condom should always be placed over the erect penis before coitus. Some couples find condom use objectionable because foreplay may have to be interrupted to apply the condom. The penis, covered by the condom, should be withdrawn before the penis becomes flaccid. Otherwise semen may escape from the condom, providing an opportunity for possible fertilization. Rather than having the condom pulled tightly over the penis before coitus, space should be left at the tip of the penis to allow the condom to hold the sperm. The client does not need a prescription for a condom with nonoxynol 9 because these are sold over the counter."

A nurse is assessing a client using light palpation. How does a nurse perform light palpation?

by indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) "To perform light palpation, the nurse indents the client's skin ½″ to ¾″, using the tips and pads of the fingers. The nurse indents the skin approximately 1½″ (3.8 cm) when performing deep palpation. THe nurse indents the skin 1″ and then releases the pressure quickly when eliciting rebound tenderness."

After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which complication?

congenital anomalies "Additional teaching is needed when the parent says that adolescents are at greater risk for congenital anomalies. Although adolescents are at greater risk for denial of the pregnancy, lack of prenatal care, low-birth-weight infant, cephalopelvic disproportion, anemia, and nutritional deficits and have a higher maternal mortality rate, studies reveal that congenital anomalies are not more common in adolescent pregnancies."

The nurse assesses a teenage girl's musculoskeletal system (see figure). What finding should the nurse document?

lordosis "This girl has an exaggeration of the lumbar spine, swayback, or lordosis. Kyphosis is an increased convexity or roundness of the curve of the thoracic spine. Scoliosis is a lateral curvature of the spine."

After trying for a year to conceive, a couple consults an infertility specialist. When obtaining a history from the husband, the nurse asks about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility?

mumps "Mumps is the childhood infectious disease that most significantly affects male fertility. Chickenpox, measles, and scarlet fever don't affect male fertility."