Module 1

A nurse observes an assistive personnel (AP) communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the AP performs which action? 1) Uses short sentences 2) Overarticulates words 3) Uses facial expressions or gestures 4) Speaks at a normal rate and volume

2) over articulate words

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take? 1) Tell the mother that the infants weight is increasing as expected 2) Tell the mother to decrease the daily number of feedings because the weight gain is excessive 3) Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes 4)Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate

1) tell the mother that the infants weight is increasing as expected Infants usually double their birth weight at 6 months and triple birth weight by 1 year

The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. What should the nurse tell the parents? 1) That this is normal behavior for an adolescent Correct 2) To restrict any social privileges until the behavior stops 3) That this type of behavior is usually the result of parents' spoiling a child 4) That their daughter will need to see a child psychologist if the behavior continues

1) that this is normal behavior for adolescents energy is focused within the self, and they can sometimes be described as egocentric or self-absorbed,

A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? 1) Use water and a cotton swab and rub the teeth 2) use diluted fluoride and rub teeth with a soft washcloth 3) use a small amount of toothpaste and a soft-bristle toothbrush 4) dip the infants pacifier in maple syrup so that the infant will suck

1) use a water and cotton swab and rub teeth they could swallow toothpaste so you don't want to do that. fluoride is recommended but they will be receiving necessary amounts in formula, cereal and from water source. Maple syrup will cause tooth decay.

A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). What should the nurse tell the adolescent? 1) Use of a latex condom can prevent transmission of STIs 2) The only way to prevent transmission of STIs is abstinence 3) Use of a latex condom is a good method for preventing pregnancy 4) A spermicide needs to be used along with a condom to prevent transmission of STIs

1) use of latex condom can prevent transmission of STIs

A nurse is assessing language development in a toddler from a bilingual family. What should the nurse expect about the child's language development? Select all that apply. 1) Is slower than expected 2) Is developing as expected 3) Is more advanced than expected 4) Will require assistance from a speech therapist 5) Will need more time to communicate with others 6) Could exhibit some lack of confidence related to communicating with others

1, 5,6 children bilingual families, twins, children other than first borns may have lower language development. need more time to communicate and could exhibit less confidence

According to Erik Erikson's developmental theory, which is a developmental task of the middle adult? Select all that apply. 1) Willingness to care for others 2) Guiding social interactions with the next generation 3) Redefining self-perception and capacity for intimacy 4) Providing guidance during interactions with children 5) Verbalizing readiness to assume parental responsibilities 6) Making decisions concerning career, marriage, and parenthood

1,2,4 primary developmental task of the middle adult is to achieve generatively = willingness to care for others, can achieve this with their own children, or friends children

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? 1) Cleansing breaths 2) Blowing repeatedly in short puffs Correct 3) Holding her breath and using the Valsalva maneuver 4) Deep inspiration and expiration at the beginning and end, respectively, of each contraction

2) Blowing repeatedly in short puffs if she pushes down before cervix is fully open she can cause injury

A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, which action should the nurse take? 1) Spend as much time as possible with the toddler 2) Keep hospital routines as similar as possible to those at home 3) Allow the toddler to play with other children in the nursing unit playroom 4) Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room

2) Keep hospital routines as similar as possible to those at home this can give the toddler a sense of control and security and ease feelings of helplessness and fear. It can decreased stress and incorporate the toddlers rituals and routines.

A nurse is performing an admission assessment on an older client who will be seen by a primary health care provider in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. What is the next action the nurse should take? 1) Report the client's concern to the primary health care provider. 2) Ask the client about medications he is taking. 3) Document the client's concern in the medical record. 4) Tell the client that sexual dysfunction is a normal age-related change.

2) ask the client about medications he is taking sexual dysfunction is not a normal process of aging, illnesses and medication can interfere with then normal sexual function

A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. Which question should the nurse ask to identify risk factors associated with the use of an oral contraceptive? 1) "Are you dieting?" 2) "Do you smoke cigarettes?" 3) "Do you engage in strenuous exercise such as jogging?" 4)"Do you normally have menstrual cramps with your periods?"

2) do you smoke cigarettes oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke

The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? 1) "I need to avoid eating fried or greasy foods." 2) "I need to be sure to drink adequate fluids with my meals." Correct 3) "I should eat five or six small meals a day rather than three full meals." 4) "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.

2) i need to be sure to drink fluids with meals to alleviate nausea and vomiting the client should avoid drinking fluids with meals

A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F (38.1°C), the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action? 1) Recheck the vital signs in 1 hour 2) Notify the nurse-midwife of the findings Correct 3) Continue collecting subjective and objective data 4) Document the findings in the client's medical record

2) notify midwife or physician a women's temp should range 98-99.6, pulse 60-90, reparations 12-20

A nurse is assessing the language development of a 9-month-old infant. Which developmental milestones does the nurse expect to note in an infant of this age? Select all that apply 1) the infant babbles 2) infant says "mama" 3) infant smiles and coos 4) infant babbles single consonants 5) Words begin to have meaning for the infant 6) the infant strings vowels and consonants together

2- infant says mama 5- words begin to have meaning for the infant 6-the infant strings vowels and consonants tg babbling is common in 3-4 months, single consonant babbling occures between 6-8 months, 1-3 month will coos

The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. What should the nurse tell the mother? 1) Hepatitis B is a concern with body piercing 2) Infection always occurs when body piercing is done 3) Body piercing is generally harmless as long as it is performed under sterile conditions Correct 4) It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)

3) Body piercing is generally harmless as long as it is performed under sterile conditions

A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information 1) I can mix the food in my infants bottle if he wont eat the food 2) Fluoride supplementation is not necessary until permanent teeth come in 3)Egg white should not be given to my infant because of the risk for an allergy 4)Meats are really important for iron, and I should start feeding meats to my infant right away

3) Egg white should not be given to my infant because of the risk for allergy egg whites should not be given prior to the first year of life because it is a common food allergen. fluoride supplementation may be given after 6 months. Rice cereal is introduced first then one fruit or vegetable at a time starting with one color food at a time. Never mix food with formula in the bottle because it may be hard for the infant to take the bottle

A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse include in the plan? 1) Encouraging at least one daytime nap 2) Discouraging the use of a night light at bedtime 3) Encouraging bedtime reading or listening to music 4) Discouraging social interaction, particularly at bedtime

3) encouraging bedtime reading or listening to music Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading listening to music

A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her primary health care provider. Which statement by the mother indicates a need for further information? 1) "My temperature needs to remain within a normal range." 2) "Frequent urination and burning when I urinate are expected." 3) "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." 4) "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs."

3) frequent urination and burnging is expected this could be a sign infection and should be reported

A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. What should the nurse tell the client? 1)The test results are normal 2) She has developed immunity to the rubella virus 3) The test will need to be repeated during the pregnancy 4) She must have been exposed to the rubella virus at some point in her life

3) test will need to be repeated client is not immune to rubella with this titer,

A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she performs which action? 1) Washes the diaper area first 2) Washes the infant's chest first 3) Uncovers only the body part being washed Correct 4) Uses a cotton-tipped swab to carefully clean inside the infant's nose

3) uncover only the body part being washed

A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse should select an activity that will assist in developing which psychosocial stage? 1) Initiative 2) Autonomy 3) A sense of trust 4) A sense of industry

4) A sense of industry the central task of a school-age years is the development of sense of industry at school-age, child replaces fantasy play with "work" at school, crafts, chores, hobbies, sports

A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client? 1) "Don't be concerned; any 2-year-old would welcome a newborn." 2) "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." 3) "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned." 4) "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."

4) Even though a 2 year old may have little perception of time, if any changes in sleeping arrangements needs to be made for the newborn they should be carried out several weeks before birth

The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? 1) schedule an appointment with a dentist for evaluation 2) rub the infants gums with baby aspirin 3) Obtain an over the counter OTC topical medication for pain relief 4) give the infant cool liquids or a popsicle and hard foods like dry toast

4) Give the infant cool liquids or a popsicle and a hard food such as dry toast some degree of discomfort during teething is normal. Hard, cold teethers and ice wrapped in cloth may provide comfort for inflamed gums

A nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm? 1) "I need to reapply spermicidal cream with repeated intercourse." 2) "The diaphragm needs to be filled with spermicidal cream before insertion." 3) "The diaphragm can be inserted as long as 6 hours before intercourse." 4) "I can leave the diaphragm in place as long as I want after intercourse."

4) I can leave the diaphragm in place as long as i want after intercourse because of the risk of toxic shock syndrome the diaphragm must not remain in place for more than 24 hours

A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. What should the nurse tell the client? 1) The procedure takes about 2 hours 2) She will be positioned on her back for the procedure 3) A probe coated with gel will be inserted into the vagina 4) That she may need to drink fluids before the test and may not void until the test has been completed

4) That she may need to drink fluids before the test and may not void until the test has been completed need the bladder to be full to push the uterus up

The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse should tell the mother that which observation is a sign of physical readiness? 1) The child has been walking for 2 years. 2) The child can eat using a fork and knife. 3) The child no longer has temper tantrums. 4) The child can remove his or her own clothing.

4) The child can remove his or her own clothing sign of physical readiness include: removing clothes, willing to let go of toy when asked, is able to sit, squat, walk well, and has been walking for 1 year

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? 1) "I need to keep large toys out of the crib." 2)"The drop side needs to be impossible for my infant to release." 3)"Wood surfaces on the crib need to be free of splinters and cracks." 4) "The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body."

4) The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infants head or body

A nurse monitoring a client in labor notes this fetal heart rate pattern (refer to figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action? 1) Stop the oxytocin (Pitocin) infusion 2) Notify the nurse-midwife or primary health care provider 3) Administer oxygen with a face mask at 8 to 10 L/min 4) Continue to monitor the client and fetal heart rate patterns

4) continue monitoring the client and fetal hr pattern early decelerations are not associated with Fetal compromise and require no intervention

A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? 1) Suspect the presence of hydrocephalus 2) Suggest to the pediatrician that a skull x-ray be performed 3) Tell the mother that the infant is growing faster than expected 4) Document these measurements in the infant's health-care record

4) document these measurements in the infants health-care record The head circumference growth rate during the first year is approximately 0.4 inch per month. By 10 to 12 months of age, the infants head and chest circumferences are equal.

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. Based on this finding, what does the nurse determine? 1) The results are negative 2) The client needs to receive the hepatitis B series of vaccines 3) The results indicate that the mother does not have hepatitis B 4) Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth

4) hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth if the mother is has the antigens in her blood then the newborn needs the vaccine after birth

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? 1) "I should drink extra fluids during the summer." 2) "I should wear cool, light clothing in warm weather." 3) "I need to wear a hat with a wide brim when I go outdoors." 4) "I need to wear additional antiperspirant and deodorant in warm weather."

4) i need to wear additional antiperspirant and deodorant in warm weather as you age the number of sweat gland decreases resulting in reduced body odor

A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which observation should the nurse expect to note as an age-related finding? 1) Thin, ridged toenails 2) Thick skin on the lower legs 3) Bounding dorsalis pedis pulse 4) Loss of hair on the lower legs

4) loss of hair on the lower legs trophic changes associated with arterial insufficiency (thin, shiny skin, thick ridged nails, loss of hair on lower legs) normal part of aging

Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication. What should the nurse tell the couple? 1) The couple should engage in coitus once a week during treatment 2) The primary health care provider should be notified immediately if breast engorgement occurs 3) If the oral tablets are not successful, the medication will be administered intravenously 4) Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

4) multiple births occur in a small percentage of clomiphene-facilitated pregnancies

A nurse is telling a pregnant client about the signs/symptoms that must be reported to the primary health care provider or nurse-midwife. The nurse tells the client that the primary health care provider or nurse-midwife should be contacted if which occurs? 1) Morning sickness 2) Breast tenderness 3) Urinary frequency 4) Puffiness of the face

4) puffiness of face danger signs in pregnancy = swelling of the fingers, puffiness of the face and around eyes, vaginal bleeding, rupture of membranes

The mother of a 9-year-old child who is 5 feet 1 inch (155 cm) in height asks a nurse about car safety seats. What should the nurse tell the mother to use? 1) Front booster seat Incorrect 2) Rear convertible seat 3) Forward-facing car seat 4) Rear seat using lap and shoulder seat belts

4) rear seat using lap and shoulder seat belts all children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection they should always use lap and shoulder restraints

A mother asks the nurse when her child should have his first dentist visit. What should the nurse tell the mother? 1) At age 3 2) Just before beginning kindergarten 3) Twelve months after the first primary tooth erupts 4) Soon after the first primary tooth erupts, usually around 1 year of age

4) soon after the frist primary tooth erupts, usually around 1 year of age the child should see the dentist soon after the first primary tooth erupts at around 1 year of age.

A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? 1) "Yes, your infant is protected from all infections." 2) "If you breastfeed, your infant is protected from infection." 3) "The transfer of your antibodies protects your infant until the infant is 12 months old." 4) "The immune system of an infant is immature, and the infant is at risk for infection."

4) the immune system of an infant is immature and the infant is at risk for infection Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood

A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. What should the nurse tell the clients? 1) It is best to do grocery shopping and other errands late in the day 2) They must stay in the house and ask a neighbor or family member to run their errands 3) Drinking eight 8-oz (240 ml) glasses of fluid each day will reduce the risk of contracting influenza. 4) Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

4) wearing a scarf around the nose and mouth will help reduce transmission of airborne viruses during peak influenza season older clients should avoid crowds to decrease the risk of contracting the flu.

A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. 1) The young adult is sensitive to criticism. 2) The young adult verbalizes unrealistic fears. 3) The young adult verbalizes disappointment with life. 4) The young adult verbalizes satisfaction with friendships. 5) The young adult has a sense of meaning and direction in life.

4) young adult verbalizes satisfaction with friendships 5) young adult has a sense of meaning and direction in life signs of emotional health in young adults = sense of meaning and direction n life, successful negotiation of transitions, absense of feelings of being cheated or disappointed by life.

The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. Which instruction should the nurse give the mother? 1 ) To bring the infant to the pediatrician's office to be checked 2) That the crust is to be expected as a normal part of healing Correct 3 )To remove the crust, using a warm, wet face cloth and a mild soap 4) that it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours

2) that the curst is to be expected as a normal part of healing

A nurse is assessing the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform? Select all that apply. 1) Put on and tie his shoes 2) Align two or more blocks 3) Washing and drying hands 4) Dress himself appropriately 5) Go to the bathroom without help 6) Turn the pages of a book one at a time

2,3,6 By 24 months, toddler can put on simple item of clothing but cannot differentiate front and back, fine motor skills for shoe tying is not developed

The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? 1) Initiative versus guilt 2) Trust versus mistrust 3) Industry versus inferiority 4) Autonomy versus doubt and shame

4) Autonomy versus doubt and shame Toddlers discover that they have wills of their own and that they can control others. The experience conflict because that they want to assert their own wills but do not want to risk losing the approval of loved ones.

A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz (3.2 kg) about car safety. What should the nurse tell the mother 1) To secure the infant in the middle of the back seat in a rear-facing infant safety seat 2) To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant 3) That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags 4) That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car

1) to secure the infant in the middle of the back seat in a rear-facing infant safety seat sdfb

A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? 6 weeks 8 weeks 12 weeks 16 weeks

16 weeks first noticed between 16-20 weeks and frequency should increase

A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on the data, which action should the nurse take? 1) Report the findings to the primary health care provider 2) Document the findings in the medical record Correct 3) Ask the primary health care provider for a prescription for a nighttime sedative 4) Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours

2) Document the findings in the medical record

A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. Where should the nurse place the tape measure? 1) In the axillary area 2) At the level of the nipples 3) 2 inches (5cm) below the nipples 4) At the level of the umbilicus

2) at the level of the nipples

A nurse is reviewing the medical notes of a client seen by the primary health care provider to determine whether the client is pregnant. What positive signs/symptoms of pregnancy would the nurse expect to see in the client's medical notes? Select all that apply. 1) Amenorrhea Incorrect 2) Palpable fetal movement 3) Thinning of the cervix 4) Auscultation of fetal heart sounds 5) Visualization of the fetus with sonography 6) Positive result on home urine test for pregnancy

2,4,5 palpable fetal movement auscultation of fetal heart visualization of the fetus with sonography

A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which action should the nurse include in the plan of care? 1) Encouraging the client to feed herself 2) Ensuring that most of the diet consists of liquids 3) Monitoring the client during meals to ensure that food is swallowed 4 )Consulting with the health care provider regarding feeding through an enteral tube

3) Monitoring the client during meals to ensure that food is swallowed want to promote independence, but observe that the food is being swallowed and not held in mouth

A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? 1) Diaphragm 2) Spermicide 3) Sterilization Correct 4) Male condom Rati

3) sterilization if the family has met their family goal then sterilization of the male or female partner may be desirable

A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. What should the nurse tell the mother? 1) To separate her children during playtime 2) That if the behavior continues, she will need to bring her children to a child psychologist 3) That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity 4)To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again

3) that if she notes that behavior she should causally tell her children to dress and direct them to another activity parents should respect the curiosity as normal without judging the toddler as bad. re-direction will limit sex plat without producing feelings of shame or anxiety

A nurse is reviewing the medical record of an older client with presbycusis. Which findings should the nurse expect to note in the client's record? Select all that apply. 1) Unilateral conductive hearing loss 2) Difficulty hearing low-pitched tones 3) Difficulty hearing whispered words in the voice test Correct 4) Improved hearing ability during conversational speech 5) Difficulty hearing consonants during conversational speech Correct 6) Gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve

3,5,6 Presbycusis, a gradual sensorineural hearing loss caused by nerve degeneration in the inner ear in older adults, typically loss is bilateral resulting in difficulty hearing high pitched tones, whispered words, consonants during conversation

A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? 1) Recheck the score in 5 minutes 2) Initiate cardiopulmonary resuscitation 3) Provide no action except to support the infant's spontaneous efforts 4) Gently stimulate the infant by rubbing his back while administering oxygen Correct

4)

A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. After reading the client's record, what is the nurse's interpretation of this sign? Select all that apply. 1) A thinning of the cervix 2) A positive sign of pregnancy 3) That cervical softening is present 4) That the cervix was seen to be violet Correct 5) Occurs at about 4 weeks of pregnancy Correct 6) Increased vascularity of the pelvic organs

456 Chadwicks sign is a violet cervix instead of pink which is an indication of pregnancy, at about 4 weeks of pregnancy increase in pelvic organs

A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid? Lettuce Oranges Broccoli Pinto beans

pinto beasn all have folic acid but beans the most

A nurse is assessing a newborn infant for jaundice. Which action should the nurse take to assess the infant for its presence? 1) Squeeze the infant's nail beds 2) Squeeze the infant's brachial area 3) Apply pressure with a finger over the umbilical area 4) Apply pressure with a finger on the infant's forehead

4) apply pressure with a finger on the infants forehead

A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? 1) Asks the mother to lie still while both the FHR and the radial pulse rate are counted. 2) Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. 3) Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. 4) Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.

2 move the fetal scope this means the scope is most likely picking up the mothers heart rate

A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted? 1) The infant turns to the side that is touched. 2) The fingers curl tightly and the toes curl forward. 3) The toes flare and the big toe is dorsiflexed. Correct 4) There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.

3

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? 1) Fetoscope 2) Stethoscope 3) Doppler transducer 4) pulse oximetry on the client and a fetoscope

3) Doppler a transducer a fetal heart can be heard at 10-12 weeks gestation with a doppler but 20 weeks for a fetoscope

A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? Prone Supine Standing Hands and knees Correct

hand on knees

A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? Pruritus Vomiting Headache Correct Hypertension

headache a spinal headache is postural, worsening when sitting up

Intramuscular phytonadione 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? Gluteal muscle Deltoid muscle Rectus femoris muscle Vastus lateralis muscle

vastus lateralis

A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. Based on this finding, which action should the nurse take? 1)Document the findings 2)Obtain a prescription for a muscle relaxant 3)Notify the primary health care provider immediately 4) Ask the primary health care provider about referring the client to a neurological specialist

1) document findings these benign tremors include intentional tremor of the hands, head nodding and tongue protrusion.

A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. Based on this finding, which action by the nurse is most appropriate? 1) Documenting the finding 2) Helping the woman get out of bed and walk 3) Performing active and passive range-of-motion exercises 4) Reporting the finding to the nurse-midwife or primary health care provider immediately

1) document the findings bradycardia can occur due to the large amount of blood loss and the body returning to central circulation

A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, which should the nurse ensure? 1) A female primary health care provider examines the woman 2) The woman's husband remains in the examining room at all times 3) The woman is examined without any other people in the examining room 4) Written permission is obtained from the woman to obtain subjective health data

1) female primary provider for exam due to religion and culture practices

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. What should the nurse tell the client? 1)Complementary alternative therapies should not be used during pregnancy 2)Devices that apply pressure alone are available over the counter Correct 3)The primary health care provider or nurse-midwife needs to provide a prescription for acupressure 4)It is all right to try any type of complementary alternative therapy to relieve the nausea

2) devices that apply pressure alone are available over the counter

A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child? Select all that apply. 1) Mastering useful skills and tools 2) Gaining independence from parents 3) Engaging in tasks they can complete 4) Developing a sense of accomplishment 5) Developing a sense of trust in the world 6) Developing a sense of control over self and body functions

1) mastering useful skills and tools 3) engaging in tasks they can complete 4)developing a sense of accomplishment this age group is focused on industry versus inferiority,

A nurse is discussing birth control methods with a client who is trying to decide which method to use. The nurse should focus on which major factor that will provide the motivation needed for consistent implementation of a birth control method? 1) Personal preference 2) Family planning goals 3) Work and home schedules 4) Desire to have children in the future

1) personal preference nurse should educate client on different birth control methods so they are equipped to make their choice

A nurse is monitoring a woman who is receiving oxytocin to induce labor. Which action should the nurse take first when suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor? 1) Stopping the oxytocin infusion Correct 2) Notifying the nurse-midwife or primary health care provider 3) Checking the woman's blood pressure and pulse 4) Increasing the intravenous (IV) rate of the nonadditive solution

1) stopping the oxytocin infusion this drug stimulates uterine smooth muscles resulting in increased strength duration and frequency of contractions

A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members should the nurse ask the client? 1) Spouse and spouse's parents 2) Foster children and their parents 3) Spouse's children from a previous marriage 4) Aunts, uncles, grandparents, and cousin

4) aunts, uncles, grandparents, cousins the other options do not share the same genetic makeup as the patient

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take? 1) Document the findings 2) Notify the primary health care provider of the finding 3) Wait 15 minutes and then recheck the FHR 4) Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time

1) document normal fetal heart during the first trimester is generally between 120-160

A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. Based on this finding, what is the most appropriate action for the nurse to take? 1) document finding 2) Contact the pediatrician 3) Place the infant in an oxygen tent 4) Wrap an extra blanket around the infant

1) document finding this is normal 30-60

A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is which? 1) Body image Correct 2) Obtaining adequate nutrition 3) Keeping up with schoolwork 4 )Obtaining adequate rest and sleep

1) Body image body image is of particular importance, concerned about weight, complexion, sexual development, acceptance by their peers

An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which? 1) Determination of fetal lung maturity Correct 2) Checking the amniotic fluid for intrauterine infection 3) Checking the fetal cells for chromosomal abnormalities 4) Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid

1) Determination of fetal lung maturity Correct

A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding? 1) Document the findings. 2) Check the client's temperature. 3) Report the findings to the nurse-midwife. 4) Obtain a sample of the amniotic fluid for laboratory analysis. Rationale

1) Document findings fluid should be clear and may have a bit of vernix (the creamy white fetal skin lubricant)

A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. How should the nurse interpret this finding? 1) A reassuring sign 2) A nonreassuring sign 3) An indication of fetal distress 4) An indication of the need to contact the primary health care provider

1) Reassuring sign Accelerations in heart rate are good signs during fetal movement

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area? 1) Chest of the fetus 2) Back of the fetus 3 )Carotid artery in the neck of the fetus 4) Brachial area of one extremity of the fetus

2) Back of fetus the fetal heart rate is most easily heard through the fetal back.

A nurse is caring for an older client who has a bronchopulmonary infection. Why should the nurse monitor the client's ability to maintain a patent airway? 1) The normal aging process increases the production of surfactant 2) The normal aging process increases respiratory system compliance 3) The normal aging process decreases an older client's ability to clear secretions 4) The normal aging process decreases the number of alveoli and increases the function of those remaining

3) the normal aging process decreases an older clients ability to clear secretions respiratory changes related to normal aging process is decreased ability to clear secretions and protect the airway

A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is most appropriate? 1) Applying an ice pack to the perineum Correct 2) Contacting the nurse-midwife or primary health care provider 3) Administering an intravenous (IV) opioid analgesic 4) Assisting the woman in taking a warm sitz bath

1) apply icepack

A nurse reviews the health history of a client who will be seeing the primary health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? 1) The client has hyperlipidemia. 2) The client has type 2 diabetes mellitus. 3) The client is being treated for hypertension. 4) The client has been treated for breast cancer

4) the client has been treated for breast cancer oral contraceptives with both estrogen and progestin are contraindication for people with a known or suspected breast cancer

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the GTPAL, what does the nurse determine? Select all that apply. G = 6 T = 2 P = 2 A = 3 L = 2

G-6, a-3, L-2 G = gravida T= term births P= preterm births A= abortion L= live births

A female client asks a nurse about the advantages of using a female condom. Which should the nurse tell the client? 1) It can be used along with a male condom 2) That it is 100% safe in preventing pregnancy 3) That it offers protection against sexually transmitted infections (STIs) 4) That it does not have to be discarded after use and can be used several times before a new one must be obtained

3) that is offers protection against sexually transmitted infections

A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which toy is most appropriate for these activities? 1)Blocks and push-pull toys 2)Finger paints and card games 3)Simple board games and puzzles 4)Videos and cutting-and-pasting toys

1) Blocks and push pull toys toddlers enjoy objects with textures, needs activity and inquisitiveness EX- large balls, blocks, water play, push pull, large crayons, painting, bubbles

A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? 1) Rely on the fact that their needs will be met. 2) Tolerate a great deal of frustration and discomfort to develop a healthy personality 3) Ignore needs for short periods to develop a healthy personality 4) Experience frustration to allow an infant to cry for a whole before meeting his or her needs

1) Rely on the fact that their needs will be met At this stage the Eriksons theory of development is establishing trust. If provided with consistent satisfying experiences that are delivered in a timely matter, the infant comes to rely on the fact that their needs are met and that in turn will be able to tolerate some degree of frustration or discomfort until those needs are met.

A nurse is determining the estimated date of delivery for a pregnant client, using Nägele's rule. Put the components for Nägele's rule in priority order. Select all that apply. 1) Adding 7 days 2) Correcting the year 3)Multiplying weeks by 2 4) Subtracting 3 months 5) Dividing the final number by 9 6) Determining the first day of last menstrual period

1,2,4,6

A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which actions does the nurse tell the client to take? Select all that apply. 1) Sleep lying on her back 2) Shower daily but avoid sitting in a bathtub 3) Apply cool compresses to the hemorrhoids Correct 4) Contact the nurse-midwife if any bleeding occurs 5) Elevate her hips on a pillow when resting or during sleep

3,5 patient should be in a side lying position with hips elevated

A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing mustard-yellow stools. What should the nurse tell the mother? 1) This is normal for breastfed infants. 2) Decrease the number of feedings by two per day. 3) Stools should be solid and pale yellow to light brown. 4) Monitor the infant for infection and, if a fever develops, contact the pediatrician.

1) this is normal for breast fed infant

The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. When should the nurse tell the mother the child should have dental examinations? 1) Once a year 2)Every 3 months 3) Every 6 months Correct 4) Whenever a new primary tooth erupts

3) every 6 months dental examinations for 4-5 year old child should be conducted every 6 months

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes that the menstrual pad was saturated in 15 minutes. What should be the nurse's next action? 1) Do nothing. This is normal. 2) Place the client in a modified Sims' position. 3) Remove the menstrual pad and replace with two pads. 4) Immediately contact the primary health care provider.

4) immediately contact the primary health care provider this indicated excessive bleeding and potential hemorrhage

A prescription is written to administer hepatitis B vaccine to a newborn infant. Before administering the vaccine, which action should the nurse take? 1) Check the infant for jaundice 2) Check the infant's temperature 3) Obtain parental consent to administer the vaccine Correct 4) Request that a hepatitis blood screen be performed on the infant

3) obtain parental consent to administer the vaccine

A school nurse provides information to the parents of school-age children regarding appropriate dental care. What should the nurse tell the parents their children should do? 1) Brush their teeth every morning and at bedtime 2) Brush and floss their teeth after meals and at bedtime 3) Brush and floss their teeth every morning and at bedtime 4) Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime

2) Brush and floss their teeth after meals and at bedtime

A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL (2.2 mmol/L). Based on this result, which action should the nurse take first? 1) Hold the next scheduled feeding 2) Contact the nurse-midwife or primary health care provider 3) Document the results in the newborn's medical record 4) Ask the laboratory to draw another blood sample in 2 hours and repeat the test

2) Contact mid wife

A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which finding is noted on the electronic monitoring recording strip? 1) Absence of accelerations after fetal movement Correct 2) Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds 3) Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement 4) Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline

1) absense of acceleration after fetal movement

A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. Based on this finding, which priority action should the nurse take? 1) Checking the client's uterine fundus 2) Notifying the nurse-midwife immediately 3 )Documenting the vital signs in the client's medical record 4) Continuing to check the client's vital signs every 15 minutes

1) checking the fundus increasing pulse could mean excessive blood loss and should be assessed

A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. Which action should the nurse take immediately? 1) Notify the nurse-midwife or primary health care provider 2) Perform a vaginal examination on the mother 3) Position the mother so that her hips are elevated Correct 4) Insert a gloved finger into the mother's vagina to feel for cord compression

3) position mother so hips are elevated this will take pressure off the umbilical cord and allow blood flow

A nurse helps a young adult conduct a personal lifestyle assessment. Why should the nurse carefully review the assessment with the young adult? 1) Young adults ignore their risk for a serious illness 2) Young adults are unable to afford health insurance 3) Young adults are exposed to hazardous substances 4) Young adults ignore physical symptoms and postpone seeking health care

4) young adults ignore physical symptoms and postpone seeking healthcare young adults are normally active and tend to ignore physical symptoms often postponing health care

After delivery, the nurse assesses the woman's uterine fundus. At what locations does the nurse expect to be able to palpate the fundus during the first 24 hours? Select all that apply. 1) In the pelvic cavity 2) 2 cm above the umbilicus 3) At the level of the umbilicus 4) Sinks to the level of the umbilicus Correct 5) Rises to a level just above the umbilicus Correct 6) Midway between the symphysis pubis and umbilicus

4,5,6