Module one: developmental stages and transitions exam

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? a. 8 weeks b. 16 weeks c. 6 weeks d. 12 weeks

b. 16 weeks rationale: Fetal movements (quickening) are first noticed by the multigravida pregnant woman at 16 to 20 weeks of gestation and gradually increase in frequency and strength. The other options are incorrect.

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? a. "Fluoride supplementation is not necessary until permanent teeth come in." b. "I can mix the food in my infant's bottle if he won't eat the food." c. "Egg white should not be given to my infant because of the risk for an allergy." d. "Meats are really important for iron, and I should start feeding meats to my infant right away."

c. "Egg white should not be given to my infant because of the risk for an allergy." rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant's intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant's intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the pediatrician's preference, fruits and vegetables may be introduced first.

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

c. Apply pressure with a finger on the infant's forehead rationale: To assess an infant for jaundice, pressure is applied with a finger over a bony area such as the nose, forehead, or sternum for several seconds to empty all capillaries in that spot. If jaundice is present, the blanched area will appear yellow before the capillaries refill. Jaundice is first noticeable in the head and then progresses gradually toward the abdomen and extremities because of the newborn infant's circulatory pattern. Squeezing the infant's nail beds and brachial area and applying pressure with a finger over the umbilical area are all incorrect methods of assessing for jaundice. Assessing for jaundice in natural light is recommended because artificial lighting and reflection from nursery walls may distort the actual skin color. Visual assessment of jaundice does not, however, provide an accurate assessment of the level of serum bilirubin.

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? a. "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." b. "My temperature needs to remain within a normal range." c. "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs." d. "Frequent urination and burning when I urinate are expected."

d. "Frequent urination and burning when I urinate are expected." rationale: The new mother is instructed to notify the nurse-midwife or primary health care provider if any of the following occurs: fever; localized areas of redness, swelling, or pain in either breast that is not relieved by support or analgesics; persistent abdominal tenderness; feelings of pelvic fullness or pressure; persistent perineal pain; frequency, urgency, or burning on urination; a change in the character of lochia (increased amount, resumption of bright-red color, passage of clots, foul odor); localized tenderness, redness, swelling, or warmth of the legs; and swelling, redness, drainage from, or separation of an abdominal incision.

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? a. spouses children from a previous marriage b. foster children and their parents c. spouse and spouses parents d. aunts, uncles, grandparents, and cousins

d. aunts, uncles, grandparents, and cousins rationale: The extended family includes relatives, (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of husband and wife and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint living situation.

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? a. "Do you smoke cigarettes?" b. "Are you dieting?" c. "Do you engage in strenuous exercise such as jogging?" d. "Do you normally have menstrual cramps with your periods?"

a. "Do you smoke cigarettes?" rationale: Oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke. The risk of thromboembolitic phenomena is increased in the presence of other risk factors, especially heavy smoking and a history of thrombosis. Additional risk factors include hypertension, cerebrovascular disease, coronary artery disease, and surgery in which postoperative thrombosis might be expected. Dieting, menstrual cramping, and strenuous exercise are not risk factors associated with the use of oral contraceptives.

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? a. "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." b. "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned." c. "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." d. "Don't be concerned; any 2-year-old would welcome a newborn."

a. "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." rationale: Sibling adaptation to the birth of an infant depends largely on age and developmental level. Very young children (2 years or younger) are unaware of the maternal changes occurring during pregnancy and are unable to understand that a new brother or sister is going to be born. Even though toddlers have little perception of time, if any changes in sleeping arrangements need to be made they should be carried out several weeks before the birth of the new baby. Until a child feels secure in the affection of his or her parents, expecting a 2-year-old to welcome a new "stranger" is unrealistic. The parents can be taught to accept strong feelings such as anger, jealousy, and frustration without judgment and to continue to reinforce the child's feelings of being loved.

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

a. "I need to wear additional antiperspirant and deodorant in warm weather." rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and reduced evaporative heat loss because of decreased sweating. The need for antiperspirants and deodorants is decreased. However, older adults are at a greater risk of heatstroke as a result of a compromised cooling mechanism; they should therefore avoid heat exposure over long periods and in areas of high humidity. The older adult should wear a hat with a wide brim and cool, lightweight, light-colored clothing when outdoors. It is also important that the older adult maintain adequate hydration, particularly during the summer and in hot climates.

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? a. A=3 b. L-2 c. T=2 d. G=6 e. P=2

a. A=3 b. L-2 d. G=6 rationale: Pregnancy outcomes can be described with the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). The GTPAL for this client would be G = 6, T = 1, P = 1, A = 3, L = 2.

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? a. Back of the fetus b. Brachial area of one extremity of the fetus c. Chest of the fetus d. Carotid artery in the neck of the fetus

a. Back of the fetus rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and to determine the location of the fetal back. The fetal heart rate is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Because of the position of the fetus in the maternal abdomen (fetal position), auscultation of the FHR over the chest, carotid artery, or brachial area is not possible.

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? a. Blowing repeatedly in short puffs b. Holding her breath and using the Valsalva maneuver c. Deep inspiration and expiration at the beginning and end, respectively, of each contraction d. Cleansing breaths

a. Blowing repeatedly in short puffs rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. The woman would not be encouraged to hold her breath or perform the Valsalva maneuver, which is a bearing-down maneuver.

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? a. Documenting the finding b. Reporting the finding to the nurse-midwife or primary health care provider immediately c. Performing active and passive range-of-motion exercises d. Helping the woman get out of bed and walk

a. Documenting the finding rationale: After delivery, bradycardia (pulse rate 50 to 70 beats per minute) may occur. The lower pulse rate reflects the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume and permits a slower heart rate to provide adequate maternal circulation. It is not necessary to notify the nurse-midwife or primary health care provider immediately, because a pulse rate of 55 beats per minute is a normal finding. The client should remain on bed rest in the immediate postpartum period. Although range-of-motion exercises are important for the client on bed rest, this action is unrelated to the data in the question. Therefore, the most appropriate nursing action is to document the finding.

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? a. family planning goals b. personal preference c. work and home schedules d. desire to have children in the future

b. personal preference rationale: Personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method. The nurse should educate the client about the various contraceptive methods available so that expressions of preference may be based on understanding. The desire to have children in the future, work and home schedules, and family planning goals may affect the choice of birth control method but are not motivating factors

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? a. Gently stimulate the infant by rubbing his back while administering oxygen b. Recheck the score in 5 minutes c. Provide no action except to support the infant's spontaneous efforts d. Initiate cardiopulmonary resuscitation

a. Gently stimulate the infant by rubbing his back while administering oxygen rationale: the Apgar score is a method of rapid evaluation of an infant's cardiorespiratory adaptation after birth. The nurse scores the infant at 1 minute and 5 minutes in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color. The infant is assigned a score of 0 to 2 in each of the five areas, and the scores are totaled. If the score ranges from 8 to 10, no action is needed other than support of the infant's spontaneous efforts and continued observation. If the score falls between 4 and 7, the nurse gently stimulates the infant by rubbing his back while administering oxygen. The nurse also determines whether the mother received opioids, which may have depressed the infant's respirations. If the score is between 1 and 3, the infant needs resuscitation.

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? a. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. b. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. c. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse. d. Asks the mother to lie still while both the FHR and the radial pulse rate are counted.

a. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic souffle (blood flowing through the umbilical cord) and the uterine souffle (blood flowing through the uterine vessels). The funic souffle is synchronized with the FHR; the uterine souffle is synchronized with the mother's pulse.

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

a. Obtain parental consent to administer the vaccine rationale: Hepatitis B vaccine is for immunization against infection caused by all known subtypes of hepatitis B virus. The usual recommended schedule is to administer the vaccine at birth, at 1 month of age, and again at 6 months of age. Parental consent must be obtained before the vaccine is administered. Checking the infant's temperature, checking for jaundice, and requesting that a hepatitis blood screen be performed on the infant are all unnecessary.

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? a. Puffiness of the face b. Urinary frequency c. Breast tenderness d. Morning sickness

a. Puffiness of the face rationale: Danger signs in pregnancy include swelling of the fingers (rings become tight), puffiness of the face or around the eyes; vaginal bleeding, with or without discomfort; rupture of the membranes; a continuous pounding headache; visual disturbances; persistent or severe abdominal pain; chills or fever; painful urination; persistent vomiting; and a change in the frequency or strength of fetal movements. Morning sickness, breast tenderness, and frequent urination are common occurrences during pregnancy and do not warrant contacting the primary health care provider or nurse-midwife.

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

a. Soon after the first primary tooth erupts, usually around 1 year of age rationale: The child should see the dentist soon after the first primary tooth erupts at around 1 year of age. Therefore the remaining options are incorrect. Parents should be aware of the dental guidelines for children and should not delay necessary dental care.

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? a. To secure the infant in the middle of the back seat in a rear-facing infant safety seat b. 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 c. 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 d. 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

a. To secure the infant in the middle of the back seat in a rear-facing infant safety seat rationale: Infants should not be restrained in the front seats of cars. If a passenger-side air bag is deployed, the air bag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb (9.1 kg) and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car.

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. a. align two or more blocks b. put on and tie his shoes c. go to the bathroom without help d. turn the pages of a book one at a time f. dress himself appropriately g. washing and drying hands

a. align two or more blocks d. turn the pages of a book one at a time g. washing and drying hands rationale: By 24 months of age, the toddler can put on simple items of clothing but cannot differentiate front and back. Some other activities that children at this age can perform include zipping large zippers, putting on shoes, washing and drying their hands, aligning two or more blocks, and turning the pages of a book one at a time. The fine motor skill needed to tie shoes is not yet developed. By the age of 4 to 5 years, the child is more independent and can dress, eat, and go to the bathroom without help.

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? a. devices that apply pressure alone are available over the counter b. complementary alternative therapies should not be sued during pregnancy c. the primary health care provider or nurse-midwife needs to provide a prescription for acupressure d. it is all right to try any type of complementary alternative therapy to relive the nausea

a. devices that apply pressure alone are available over the counter rationale: As a complementary alternative therapy, acupressure over the Neiguan acupuncture point (approximately three fingers' width above the wrist crease on the inner arm) is performed with the use of electrical impulses or with a device that applies pressure alone. Devices that apply an electrical impulse over this point require a prescription from a primary health care provider or nurse-midwife. Devices that apply pressure alone are available over the counter. Certain types (those that are noninvasive and are not harmful) may be acceptable for use during pregnancy. Not all types of complementary alternative therapies can be used during pregnancy, because some may be harmful to the mother, fetus, or both.

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? a. document the findings b. notify the primary health care provider immediately c. obtain a prescription for a muscle relaxant d. ask the primary health care provider about referring the client to a neurological specialist

a. document the findings rationale: Senile tremors are occasionally noted in clients in later adulthood. These benign tremors include intentional tremor of the hands, head-nodding (as if saying yes), and tongue protrusion. Because this finding is an age-related occurrence, obtaining a prescription for a muscle relaxant, notifying the primary health care provider immediately, and asking about referring the client to a neurological specialist are unnecessary and incorrect

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 a. engaging in tasks they can complete b. developing a sense of trust in the world c. developing a sense of control over self and body functions d. mastering useful skills and tools e. developing a sense of accomplishment f. gaining independence from parents

a. engaging in tasks they can complete d. mastering useful skills and tools e. developing a sense of accomplishment rationale: According to Erikson's theory of psychosocial development, the school-age child's task is to master useful skills and tools of the culture (industry versus inferiority). Gaining independence from parents is the psychosocial task of the adolescent. Developing a sense of trust in the world is the psychosocial task of an infant. Developing a sense of control over self and body functions is the psychosocial task of the toddler.

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. a. is slower than expected b. is developing as expected c. could exhibit some lack of confidence related to communicating with others d. will require assistance from a speech therapist e. is more advanced than expected f. will need more time to communicate with others

a. is slower than expected c. could exhibit some lack of confidence related to communicating with others f. will need more time to communicate with others rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. They also need more time to communicate with others and could exhibit some lack of confidence when communicating with others. A child from a bilingual family does not require assistance from a speech therapist to ensure language development.

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. a. subtracting 3 months b. correcting the year c. dividing the final number by 9 d. determining the first day of last menstrual period e. multiplying weeks by 2 f. adding 7 days

a. subtracting 3 months b. correcting the year d. determining the first day of last menstrual period f. adding 7 days rationale: Nägele's rule is often used to establish the estimated date of delivery. The components of Nägele's rule involves determining the date of the first day of the last normal menstrual period, subtracting 3 months, adding 7 days and then correcting the year.

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? a. tell the mother that the infant weight is increasing as expected b. tell the mother that semisolid foods should not be introduced until the infant weight stabilizes c. tell the mother to decrease the daily number of feedings because the weight gain is excessive d. tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate

a. tell the mother that the infant weight is increasing as expected rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz (2.9 kg), at birth, a weight of 13 lb (5.9 kg) at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age.

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? a. that the cervix was seen to be violet b. occurs at about 4 weeks of pregnancy c. that cervical softening is present d. increased vascularity of the pelvic organs e. a positive sign of pregnancy f. a thinning of the cervix

a. that the cervix was seen to be violet b. occurs at about 4 weeks of pregnancy d. increased vascularity of the pelvic organs rationale: One probable sign of pregnancy is the Chadwick sign — violet coloration of the cervix, which is normally pink. The color change, which also extends into the vagina and labia, occurs at about 4 weeks of pregnancy because of increased vascularity of the pelvic organs. Thinning of the cervix is termed the Hegar sign, and softening of the cervix is called the Goodell sign. These are both probable signs of pregnancy.

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. a. the young adult has a sense of meaning and direction in life b. the young adult verbalizes satisfaction with friendships c. the young adult verbalizes unrealistic fears d. the young adult is sensitive to criticism e. the sound adult verbalizes disappointment with life

a. the young adult has a sense of meaning and direction in life b. the young adult verbalizes satisfaction with friendships rationale: Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Signs of emotional health in the young adult include a sense of meaning and direction in life, successful negotiation of transitions, absence of feelings of being cheated or disappointed by life, attainment of several long-term goals, satisfaction with personal growth and development, reciprocated feelings of love for a partner, satisfaction with social interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and no unrealistic fears.

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? a. use of a latex condom can prevent transmission of STIs b. use of latex condom is a good method for preventing pregnancy c. a spermicide needs to be used along with a conform to prevent transmission of STIs d. the only way to prevent transmission of STIs is

a. use of a latex condom can prevent transmission of STIs rationale: Use of a condom during intercourse can prevent transmission of STIs. Abstinence is not the only way to prevent transmission of an STI. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs.

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? a. use water and cotton swab and rub the teeth b. Use a small amount of toothpaste and a soft-bristle toothbrush c. Use diluted fluoride and rub the teeth with a soft washcloth d. Dip the infant's pacifier in maple syrup so that the infant will suck

a. use water and cotton swab and rub the teeth rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant's pacifier in maple syrup is unacceptable because of the risk of tooth decay.

An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? a. An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? b. "A loss of melanin occurs in the normal aging process." c. "The skin on the scalp becomes thin, causing moisture to escape." d. "It is caused by hereditary factors."

b. "A loss of melanin occurs in the normal aging process." rationale: The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from ultraviolet rays, paler skin color, and graying hair. Although the skin becomes thinner with the aging process and the number of sweat glands and blood vessels decreases, these changes are unrelated to graying hair. Heredity factors influence when the process of graying begins but do not cause the graying of hair.

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? a. "The diaphragm can be inserted as long as 6 hours before intercourse." b. "I can leave the diaphragm in place as long as I want after intercourse." c. "I need to reapply spermicidal cream with repeated intercourse." d. "The diaphragm needs to be filled with spermicidal cream before insertion."

b. "I can leave the diaphragm in place as long as I want after intercourse." rationale: The diaphragm may be inserted as long as 6 hours before intercourse and must remain in place for at least 6 hours after. Because of the risk of toxic shock syndrome, the diaphragm must not remain in place for more than 24 hours. The diaphragm must be filled with spermicidal cream or jelly before insertion, and the spermicide must be reapplied before intercourse is repeated.

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? a. "I should eat five or six small meals a day rather than three full meals" b. "I need to be sure to drink adequate fluids with my meals" c. "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning" d. "I need to avoid eating fried and greasy food"

b. "I need to be sure to drink adequate fluids with my meals" rationale: To alleviate nausea and vomiting, the client should avoid drinking fluids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage.

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? a. The woman's husband remains in the examining room at all times b. A female primary health care provider examines the woman c. Written permission is obtained from the woman to obtain subjective health data d. The woman is examined without any other people in the examining room

b. A female primary health care provider examines the woman rationale: Fear, modesty, and a desire to avoid examination by men may keep some women from seeking health care during pregnancy. In many cultures (e.g., Muslim, Hindu, Latino), exposure of a woman's genitals to men is considered demeaning. Nurses must remember that the reputations of women from these cultures depend on their demonstrated modesty. It is best for a female primary health care provider or practitioner to perform the examination. If this is not possible, the woman should be carefully draped, with her legs completely covered. A female nurse should remain with the woman at all times. Obtaining permission from the husband may be necessary before an examination or treatment can be performed.

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? a. Document the client's concern in the medical record. b. Ask the client about medications he is taking. c. Tell the client that sexual dysfunction is a normal age-related change. d. Report the client's concern to the primary health care provider.

b. Ask the client about medications he is taking. rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. Although the nurse may report the client's concern and document the concern in his medical record, the next action is to ask the client about the medications he is taking.

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? a. Document the results in the newborn's medical record b. Contact the nurse-midwife or primary health care provider c. Ask the laboratory to draw another blood sample in 2 hours and repeat the test d. Hold the next scheduled feeding

b. Contact the nurse-midwife or primary health care provider rationale: The blood glucose level for a newborn infant should remain above 40 mg/dL (2.2 mmol/L). If glucose is not constantly available to the brain, permanent damage may occur. The nurse would most appropriately contact the nurse-midwife or primary health care provider to obtain prescriptions regarding feeding the infant with a low blood glucose. The nurse would also follow agency policy regarding feeding infants with a low blood glucose level if such a policy exists. A common practice is to feed the infant if the glucose level is 40 mg/dL (2.2 mmol/L) or less. Holding the next scheduled feeding is harmful. Although the nurse would document the laboratory result, this is not the most appropriate initial action. Another blood sample may need to be drawn if it is prescribed, but asking the laboratory to repeat the test in 2 hours is not the appropriate action.

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. a. shower daily but avoid sitting in a bathtub b. elevate her hips on a pillow when resting or during sleep c. sleep lying on her back d. contact the nurse-midwife if any bleeding occurs e. apply cool compresses to the hemorrhoids

b. elevate her hips on a pillow when resting or during sleep e. apply cool compresses to the hemorrhoids rationale: To relieve the discomfort of hemorrhoids, the client should take frequent tepid baths. The client is also instructed to apply cool witch hazel compresses or anesthetic ointment to the hemorrhoids and to assume a side-lying position with the hips elevated on a pillow. The client may experience some bleeding, which is normal. However, if the bleeding persists, the primary health care provider or nurse-midwife should be contacted.

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? a. Checking the amniotic fluid for intrauterine infection b. Determination of fetal lung maturity c. Checking the fetal cells for chromosomal abnormalities d. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid

b. Determination of fetal lung maturity rationale: The most common indications for amniocentesis in the third trimester are determination of fetal lung maturity and evaluation of the fetus' condition when the woman has Rh isoimmunization. The most common purpose for midtrimester amniocentesis is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Midtrimester amniocentesis is also performed to evaluate the fetus' condition when the woman is sensitized to Rh-positive blood, to diagnose intrauterine infection, and to investigate amniotic-fluid AFP and acetylcholinesterase when the maternal serum AFP concentration is increased.

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? a. checking the woman's blood pressure and pulse b. Stopping the oxytocin infusion c. Increasing the intravenous (IV) rate of the nonadditive solution d. Notifying the nurse-midwife or primary health care provider

b. Stopping the oxytocin infusion rationale: Oxytocin stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of uterine contractions. The nurse monitors the client who is receiving oxytocin closely and, if uterine hypertonicity or a nonreassuring FHR pattern, such as late decelerations occurs, intervenes to reduce uterine activity and increase fetal oxygenation. The nurse would first stop the oxytocin infusion. The nurse would next increase the IV rate of the nonadditive solution, place the woman in a side-lying position, and administer oxygen through a snug face mask at a rate of 8 to 10 L/min. The nurse would then notify the nurse-midwife or primary health care provider of the adverse reaction, the nursing interventions taken, and the response to interventions. The nurse would monitor the woman's vital signs while she is receiving oxytocin, but this would not be the first action in this situation.

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? a. To bring the infant to the pediatrician's office to be checked b. That the crust is to be expected as a normal part of healing c. That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours d. To remove the crust, using a warm, wet face cloth and a mild soap

b. That the crust is to be expected as a normal part of healing rationale: After circumcision, a yellow crust may form over the circumcision site. This crust is a normal part of healing and should not be removed. The mother should be told to expect this occurrence. Yellow crusting or discharge is not a sign of infection, and the pediatrician does not need to be notified, because the finding is to be expected.

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? a. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. b. The toes flare and the big toe is dorsiflexed. c. The infant turns to the side that is touched. d. The fingers curl tightly and the toes curl forward.

b. The toes flare and the big toe is dorsiflexed. rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.

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? a. Decrease the number of feedings by two per day. b. This is normal for breastfed infants. c. Stools should be solid and pale yellow to light brown. d. Monitor the infant for infection and, if a fever develops, contact the pediatrician.

b. This is normal for breastfed infants. rationale: Breastfed infants may pass mustard-yellow stools. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. Decreasing the number of feedings might be harmful to the newborn. Because this finding is an expected occurrence in a breastfed infant, infection is not a concern.

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? a. a non reassuring sign b. a reassuring sign c. an indication of the need to contact the primary health care provider d. an indication of fetal distess

b. a reassuring sign rationale: When assessing the FHR, the nurse determines that the findings are reassuring or whether further steps should be taken to clarify data or correct problems. Reassuring signs include an average rate between 120 and 160 beats per minute at term; a regular rhythm or a rhythm with slight fluctuations; accelerations from the baseline rate, often occurring with fetal movement; and the absence of decreases from the baseline rate. A nonreassuring sign suggests fetal distress, warranting immediate intervention and indicating the need to contact the primary health care provider.

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? a. simple board games and puzzles b. blocks and push pull toys c. videos and cutting and pasting toys d. finger paints and card games

b. blocks and push pull toys rationale: Toys for the toddler should meet the child's needs for activity and inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger paints, and bubbles; push-pull toys; large balls; sand and water play; blocks; painting; coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board games, videos, and cutting-and-pasting toys are more appropriate play activities for the preschooler.

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? a. experience frustration to allow an infant to cry for a while before meeting his or her needs b. rely on the fact that their needs will be met c. tolerate a great deal of frustration and discomfort to develop a healthy personality d. ignore needs for short periods to develop a healthy personality

b. rely on the fact that their needs will be met rationale: According to Erikson's theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect.

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? a. to separate her children during playtime b. that if she notes the behavior again she should casually tell her children to dress and to direct them to another activity c. that if the behavior continues, she will need to bring her children to a child psychologist d. to tell her children that what they are doing is bad and that they will be punished if they are caught doing it again

b. that if she notes the behavior again she should casually tell her children to dress and to direct them to another activity rationale: Sex play and masturbation are common among toddlers. Parents should respect the toddler's curiosity as normal without judging the toddler as bad. Parents who discover children involved in sex play may casually tell them to dress and direct them to another play activity, thereby limiting sex play without producing feelings of shame or anxiety. Bringing the children to a child psychologist, separating them at play, and punishing them are all inappropriate.

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. a. the infant smiles and coos b. words begin to have meaning for the infant c. the infant babbles single consonants d. the infant says "mama" e. the infant strings vowels and consonants together f. the infant babbles

b. words begin to have meaning for the infant d. the infant says "mama" e. the infant strings vowels and consonants together rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age.

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? a. Administering an intravenous (IV) opioid analgesic b. Assisting the woman in taking a warm sitz bath c. Applying an ice pack to the perineum d. Contacting the nurse-midwife or primary health care provider

c. Applying an ice pack to the perineum rationale: Ice causes vasoconstriction and is most effective if applied to the perineal area soon after birth to prevent edema and numb the area. Ice is used for the first 12 to 24 hours after a vaginal birth. Sitz baths, which provide continuous circulation of water, cleanse and comfort the traumatized perineum. Warm water is most effective after 24 hours have elapsed since delivery. An IV opioid analgesic is not necessary. Rather, an anesthetic spray that will decrease surface discomfort may be used. It is not necessary to notify the nurse-midwife or primary health care provider.

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? a. At the level of the umbilicus b. 2 inches (5cm) below the nipples c. At the level of the nipples d. In the axillary area

c. At the level of the nipples rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head's circumference. The average circumference of the chest is 30.5 to 33 cm (12 to 13 inches). (If molding of the head is present, the head and chest measurements may be equal at birth.) The other options are incorrect anatomical areas for measuring chest circumference.

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? a. Place the infant in an oxygen tent b. Wrap an extra blanket around the infant c. Document the findings d. Contact the pediatrician

c. Document the findings rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths per minute (average 40). The nurse would document the findings. Contacting the pediatrician, placing the infant in an oxygen tent, and wrapping an extra blanket around the infant are all unnecessary actions

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? a. Discouraging social interaction, particularly at bedtime b. Encouraging at least one daytime nap c. Encouraging bedtime reading or listening to music d. Discouraging the use of a night light at bedtime

c. Encouraging bedtime reading or listening to music rationale: 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 or listening to music. The use of a night light will foster an environment that is both helpful and safe.

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? a. The client needs to receive the hepatitis B series of vaccines b. The results are negative c. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth d. The results indicate that the mother does not have hepatitis B

c. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth rationale: A hepatitis B screen is performed to determine the presence of antigens in maternal blood. If they are present, the newborn will need to receive hepatitis immune globulin and vaccine soon after birth. Therefore, noting that the results are negative, noting that the client needs to receive the hepatitis B series of vaccines, and noting that the results indicate that the mother does not have hepatitis B are all incorrect interpretations.

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? a. Remove the menstrual pad and replace with two pads. b. Place the client in a modified Sims' position. c. Immediately contact the primary health care provider. d. Do nothing. This is normal.

c. Immediately contact the primary health care provider. rationale: If the menstrual pad is saturated in 15 minutes, it indicates excessive bleeding. In that case, the nurse should immediately contact the primary health care provider. Lochia is the discharge from the uterus, consisting of blood from the vessels of the placental site and debris from the deciduas, occurring during the postpartum period. Use the following guide to determine the amount of flow: scant = less than 2.5 cm (1 inch) on menstrual pad in 1 hour; light = less than 10 cm (4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

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? a. Document the findings in the client's medical record b. Continue collecting subjective and objective data c. Notify the nurse-midwife of the findings d. Recheck the vital signs in 1 hour

c. Notify the nurse-midwife of the findings rationale: The woman's temperature should range from 98° F to 99.6° F (36.7°C to 37.6°C). The pulse rate should be 60 to 90 beats per minute, and respirations should be 12 to 20 breaths per minute. A temperature of 100.4° F (38°C) or higher, especially in the presence of an increased pulse rate and faster respirations, suggests infection, and the nurse-midwife or primary health care provider should be notified. Although the findings would be documented, the nurse would most appropriately contact the nurse-midwife or primary health care provider. Once the nurse has contacted the nurse-midwife or primary health care provider, the nurse would continue the assessment. Vital signs would be rechecked as prescribed or in accordance with agency protocol.

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? a. Male condom b. Diaphragm c. Sterilization d. Spermicide

c. Sterilization rationale: If family planning goals have already been met, sterilization of the male or female partner may be desirable. When sexual activity is limited, use of a spermicide, condom, or diaphragm may be most appropriate.

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? a. Uses a cotton-tipped swab to carefully clean inside the infant's nose b. Washes the diaper area first c. Uncovers only the body part being washed d. Washes the infant's chest first

c. Uncovers only the body part being washed rationale: Bathing should start with the eyes and face, usually the cleanest areas. Next, the external ear and the areas behind the ears are cleansed. The infant's neck should be washed because formula, lint, or breast milk often accumulates in the folds of the neck. The hands and arms are then washed. Next, the infant's legs are washed, and the diaper area is washed last. The person administering the bath should keep the infant warm by uncovering only the area being washed. Cotton-tipped swabs are not used to clean the infant's ears or nose because injury could occur if the infant was to move suddenly.

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? a. Drinking eight 8-oz (240 ml) glasses of fluid each day will reduce the risk of contracting influenza. b. It is best to do grocery shopping and other errands late in the day c. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses d. They must stay in the house and ask a neighbor or family member to run their errands

c. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses rationale: During peak influenza season, older clients should avoid crowds to decrease the risk of contracting influenza. The nurse should encourage clients to do their shopping and other errands early in the morning, when crowds are smaller, or to have someone else shop for them. The use of a scarf across the nose and mouth can help reduce the transmission of airborne viruses. Drinking eight 8-oz (240 ml) glasses of fluid a day will not reduce the risk of contracting influenza; however, it will prevent dehydration if illness occurs.

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? a. autonomy b. a sense of trust c. a sense of industry d. initiative

c. a sense of industry rationale: According to Erikson, the central task of the school-age years is the development of a sense of industry. The school-age child replaces fantasy play with "work" at school, crafts, chores, hobbies, and athletics. Development of trust is the task of infancy. Development of autonomy is the task of toddlerhood. Development of initiative is the task of the preschooler.

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. a. thinning of the cervix b. amenohhea c. auscultation of fetal heart sounds d. palpable fetal movement e. visualization of the fetus with sonography f. positive results on home urine test for pregnancy

c. auscultation of fetal heart sounds d. palpable fetal movement e. visualization of the fetus with sonography rationale: The positive indicators of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus with sonography. Amenorrhea is a presumptive sign of pregnancy because it is experienced and reported by the woman. Presumptive signs are not reliable indicators of pregnancy, because any may be caused by conditions other than pregnancy. Thinning of the cervix (the Hegar sign) and a positive pregnancy test result are probable indicators of pregnancy. A false-positive pregnancy test result may occur as a result of an error in reading, the presence of protein or blood in the urine, a recent pregnancy, a recent first-trimester abortion, or medications the client is taking.

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? a. suggest to the pediatrician that a skull x-ray be performed b. tell the mother that the infant is growing faster than expected c. document these measurements in the infants healthcare record d. suspect the presence of hydrocephalus

c. document these measurements in the infants healthcare record rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect.

According to Erik Erikson's developmental theory, which is a developmental task of the middle adult? a. making decisions concerning career, marriage, and parenthood b. verbalizing readiness to assume parental responsibilities c. guiding social interaction with the next generation d. providing guidance during interactions with children e. redefining self-perception and capacity for intimacy f. willingness to care for others

c. guiding social interaction with the next generation d. providing guidance during interactions with children f. willingness to care for others rationale: According to Erikson's developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Making decisions concerning career, marriage, and parenthood; redefining self-perception and capacity for intimacy; and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult.

A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? a. supine b. standing c. hands and knees d. prone

c. hands and knees rationale: "Back labor," in which the back of the fetal head puts pressure on the woman's sacral promontory (occiput posterior position), is common. The discomfort of back labor is difficult to relieve with medication alone. Positions that encourage the fetus to move away from the sacral promontory are the hands-and-knees position and leaning forward over a birthing ball (a sturdy ball similar to a beach ball). These positions reduce back pain and enhance the internal-rotation mechanism of labor. It would be difficult for the woman to assume a prone position. The supine position places the client at risk for supine hypotension. A standing position might increase pressure, worsening the woman's backache.

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? a. hypertension b. pruritus c. headache d. vomiting

c. headache rationale: The adverse effects associated with a subarachnoid block include maternal hypotension, bladder distention, and postdural headache. Postdural headache occurs as a result of cerebrospinal fluid leakage at the site of dural puncture. A spinal headache is postural, worsening when the woman is upright and possibly disappearing when she is lying flat. Bed rest with oral or intravenous hydration helps relieve the headache. Nausea, vomiting, and pruritus are adverse effects associated with the use of intrathecal opioids.

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? a. allow the toddler to play with other children in the nursing unit playroom b. allow the toddler to select toys from the nursing unit playroom that can be brought into the toddlers hospital room c. keep hospital routines as similar as possible to those at home d. spend as much time as possible with the toddler

c. keep hospital routines as similar as possible to those at home rationale: The nurse can decrease the stress of hospitalization for the toddler by incorporating the toddler's usual rituals and routines from home into nursing care activities. Keeping hospital routines as similar to those of home as possible and recognizing ritualistic needs gives the toddler some sense of control and security and eases feelings of helplessness and fear. Spending as much time as possible with the toddler and allowing the toddler to play with other children and select the toys he would like to play with may be appropriate interventions, but keeping the hospital routine as similar as possible to the routine at home will best maintain the toddler's sense of control and security and ease feelings of helplessness and fear.

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? a. rear convertible seat b. forward-facing car seat c. rear seat using lap and shoulder seat belts d. front booster seat

c. rear seat using lap and shoulder seat belts rationale: All infants and toddlers should ride in a Rear-Facing Car Seat until they are at least 2 years of age or until they reach the highest weight or height allowed by their car seat's manufacturer. ​Any child who has outgrown the rear-facing weight or height limit for their convertible car seat should use a Forward-Facing Car Seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat manufacturer. All children whose weight or height is above the forward-facing limit for their car seat should use a Belt-Positioning Booster Seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches (145 cm) in height and are between 8 and 12 years of age.​ When children are old enough and large enough for the vehicle seat belt to fit them correctly, they should always use Lap and Shoulder Seat Belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

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? a. the child no longer has temper tantrums b. the child can eat using a fork and knife c. the child can remove his or her own clothing d. the child has been walking for 2 years

c. the child can remove his or her own clothing rationale: Signs of physical readiness for toilet training include the following: The child can remove his/her own clothing; is willing to let go of a toy when asked; is able to sit, squat, and walk well; and has been walking for 1 year. Using a fork and knife, walking for 2 years, and an absence of temper tantrums are not signs of physical readiness.

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? a. the drop side needs to be impossible for my infant to release b. I need to keep large toys out of the crib c. the distance between the slats needs to be no more than4 inches (10 cm) wide to prevent entrapment of my infants head or body d. wood surfaces on the crib need to be free of splinters and cracks

c. the distance between the slats needs to be no more than4 inches (10 cm) wide to prevent entrapment of my infants head or body rationale: The distance between slats must be no more than 2 ⅜ inches (6 cm) to prevent entrapment of the infant's head and body. The mesh in a mesh-sided crib should have openings smaller than ¼ inch (.5 cm). The drop side must be impossible for the infant to release, and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother should avoid placing large toys in the crib, because an older infant may use them as steps to climb over the side, possibly resulting in serious injury.

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? a. she has developed immunity to the rubella b. the test results are normal c. the test will beed to be repeated during the pregnancy d. she must have been exposed to the rubella virus at some point in her life

c. the test will beed to be repeated during the pregnancy rationale: A client is not immune to rubella if the titer is 1:8 or less. If the client is not immune, retesting will be performed during the pregnancy. Additionally, rubella immunization is required after delivery if the client is not immune. Therefore telling the client that she has developed immunity to the rubella virus, telling her that she may have been exposed to rubella, and telling her that the test results are normal are all incorrect.

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? a. "Yes, your infant is protected from all infections." b. "The transfer of your antibodies protects your infant until the infant is 12 months old." c. "If you breastfeed, your infant is protected from infection." d. "The immune system of an infant is immature, and the infant is at risk for infection."

d. "The immune system of an infant is immature, and the infant is at risk for infection." rationale: Transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T-lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection.

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? a. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime b. Brush and floss their teeth every morning and at bedtime c. Brush their teeth every morning and at bedtime d. Brush and floss their teeth after meals and at bedtime

d. Brush and floss their teeth after meals and at bedtime rationale: School-age children are able to assume responsibility for their own dental hygiene. Good oral health habits tend to be carried into the adult years, helping prevent cavity formation for a lifetime. Thorough brushing with fluoride toothpaste followed by flossing between the teeth should be done after meals and before bedtime. It is important that parents set up a routine schedule for the child that promotes good daily oral hygiene and gives them responsibility for their own dental care.

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? a. Documenting the vital signs in the client's medical record b. Notifying the nurse-midwife immediately c. Continuing to check the client's vital signs every 15 minutes d. Checking the client's uterine fundus

d. Checking the client's uterine fundus rationale: During the fourth stage of labor, the woman's vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure decreases as the blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is that the uterus is not firmly contracting and compressing open vessels at the placental site. Therefore the nurse should check the client's uterine fundus for firmness, height, and positioning. Notifying the nurse-midwife immediately is not necessary unless the nurse is unable to determine the cause of bleeding and is unable to correct it. Continuing to check the client's vital signs every 15 minutes will delay necessary intervention. Although the findings will need to be documented, the priority action is to check the client's uterine fundus for bleeding.

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? a. Wait 15 minutes and then recheck the FHR b. Notify the primary health care provider of the finding c. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time d. Document the findings

d. Document the findings rationale: The normal fetal heart depends on gestational age (usually higher in the first trimester) and is generally in the range of 120 to 160 beats per minute. A FHR of 160 beats per minute is within the normal range, so documentation is the only action indicated.

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? a. Check the client's temperature. b. Obtain a sample of the amniotic fluid for laboratory analysis. c. Report the findings to the nurse-midwife. d. Document the findings.

d. Document the findings. rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

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? a. Stethoscope b. Fetoscope c. Pulse oximetry on the client and a fetoscope d. Doppler transducer

d. Doppler transducer rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds.

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? a. Schedule an appointment with a dentist for a dental evaluation b. Obtain an over-the-counter (OTC) topical medication for gum-pain relief c. Rub the infant's gums with baby aspirin that has been dissolved in water d. Give the infant cool liquids or a Popsicle and hard foods such as dry toast

d. Give the infant cool liquids or a Popsicle and hard foods such as dry toast rationale: Although sometimes asymptomatic, teething is often signaled by behaviors such as nighttime awakening, daytime restlessness, increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health-care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the healthcare provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child's age, can relieve discomfort.

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? a. Thick skin on the lower legs b. Bounding dorsalis pedis pulse c. Thin, ridged toenails d. Loss of hair on the lower legs

d. Loss of hair on the lower legs rationale: In later adulthood, the dorsalis pedis and posterior tibial pulses may become more difficult to find. They would not be bounding. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick, ridged nails; loss of hair on the lower legs) also occur normally with aging.

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? a. Ensuring that most of the diet consists of liquids b. Encouraging the client to feed herself c. Consulting with the health care provider regarding feeding through an enteral tube d. Monitoring the client during meals to ensure that food is swallowed

d. Monitoring the client during meals to ensure that food is swallowed rationale: Clients with dysphagia must be assisted during meals, and the nurse should carefully observe the client to ensure that foods are successfully swallowed instead of being trapped in the mouth. The diet should be nutritionally balanced and consist of both solids and liquids. Aspiration of liquids or solids is possible and may lead to aspiration pneumonia. Thickeners can be added to liquids, because thin liquids are most difficult to swallow for clients with dysphagia. Clients with severe dysphagia may require enteral tube feedings, but there is no information in the question to indicate that the dysphagia is severe.

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? a. The primary health care provider should be notified immediately if breast engorgement occurs b. If the oral tablets are not successful, the medication will be administered intravenously c. The couple should engage in coitus once a week during treatment d. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

d. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies rationale: Multiple births (usually twins) occur in a small percentage (8% to 10%) of clomiphene-facilitated pregnancies, and the couple should be informed of this. The medication is available in 50-mg tablets for oral use. There is no available intravenous form. Breast engorgement is a common side effect of the medication that reverses after medication withdrawal. When ovulation does occur as a result of use of clomiphene, it is usually within 5 to 10 days after the last dose. The couple is instructed to engage in coitus at least every other day during this time.

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? a. Notify the nurse-midwife or primary health care provider b. Perform a vaginal examination on the mother c. Insert a gloved finger into the mother's vagina to feel for cord compression d. Position the mother so that her hips are elevated

d. Position the mother so that her hips are elevated rationale: Conditions that restrict blood flow through the umbilical cord may result in variable decelerations. If cord compression is suspected, the mother is immediately repositioned. She may be turned to her side, or her hips may be elevated to shift the fetal presenting part toward her diaphragm. A hands-and-knees position may also reduce compression of a cord that is trapped behind the fetus. Several position changes may be required before the pattern improves or resolves. The nurse may need to contact the nurse-midwife or primary health care provider, but this would not be the immediate action. Although the nurse may check the woman's vaginal area for the presence of the umbilical cord, a vaginal exam is not performed because of the possibility of further compromise of blood flow through the umbilical cord. Because of this risk, the nurse would not insert a gloved finger into the vagina to feel for the cord.

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? a. She will be positioned on her back for the procedure b. The procedure takes about 2 hours c. A probe coated with gel will be inserted into the vagina d. That she may need to drink fluids before the test and may not void until the test has been completed

d. That she may need to drink fluids before the test and may not void until the test has been completed rationale: For a transabdominal ultrasound, the woman is positioned on her back, with her head elevated, but is turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure takes 10 to 30 minutes. For transvaginal ultrasonography, a transvaginal probe is inserted into the vagina.

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? a. To restrict any social privileges until the behavior stops b. That their daughter will need to see a child psychologist if the behavior continues c. That this type of behavior is usually the result of parents' spoiling a child d. That this is normal behavior for an adolescent

d. That this is normal behavior for an adolescent rationale: Identity formation is the major developmental task of adolescence. Energy is focused within the self, and the adolescent is sometimes described as egocentric or self-absorbed. Frustrated parents often describe teenagers during this phase as self-centered, lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on himself or herself, and determine who he or she is going to be. Erikson describes the conflict of this phase of psychosocial development as identity formation versus role confusion. The assertions that a psychologist is needed and that the behavior is the result of spoiling are incorrect. Restriction of social privileges will cause resentment and rebellion in the adolescent.

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? a. industry versus inferiority b. initiative versus guilt c. trust versus mistrust d. autonomy versus doubt and shame

d. autonomy versus doubt and shame rationale: According to Erikson, the toddler is struggling with the developmental task of acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers discover that they have wills of their own and that they can control others. Asserting their wills and insisting on their own way, however, often lead to conflict with those they love, whereas submissive behavior is rewarded with affection and approval. Toddlers experience conflict because they want to assert their own wills but do not want to risk losing the approval of loved ones. Trust versus mistrust is the developmental task of the infant. Initiative versus guilt is the developmental task of the preschool-age child. Industry versus inferiority is the developmental task of the school-age child.

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? a. keeping up with schoolwork b. obtaining adequate rest and sleep c. obtaining adequate nutrition d. body image

d. body image rationale: Body image is of particular importance to an adolescent. Teenagers tend to be concerned about their weight, complexion, sexual development, and acceptance by their peers. They are not concerned about obtaining adequate nutrition and tend to eat fast foods and junk foods and may experiment with weight-management techniques such as fasting, diet pills and laxatives, self-induced vomiting, and fad diets. Keeping up with schoolwork may be important to some teenagers, but it is not usually the primary concern. Along with engaging in increasingly independent activities, teenagers tend to stay up late and have difficulty waking in the morning. Obtaining adequate rest and sleep is not teenagers' primary concern.

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. a. improved hearing ability during conversational speech b. difficulty hearing low-pitched tones c. unilateral conductive hearing loss d. difficulty hearing consonants during conversational speech e. gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve f. difficulty hearing whispered words in the voice test

d. difficulty hearing consonants during conversational speech e. gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve f. difficulty hearing whispered words in the voice test rationale: Presbycusis, a gradual sensorineural hearing loss caused by nerve degeneration in the inner ear or auditory nerve. It is the most common form of hearing loss in older adults. Typically the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and difficulty hearing consonants during conversational speech.

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? a. encourage the client to consume stimulants such as caffeinated coffee or tea during daytime hours b. report the findings to the primary health care provider c. ask the primary health care provider for a prescription for a nighttime sedative d. document the findings in the medical record

d. document the findings in the medical record rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Because the reported data are normal age-related changes, the nurse would document the findings. There is no reason to report the findings to the primary health care provider. Sedatives should be avoided. The consumption of caffeinated beverages is likely to increase disruption of sleep patterns.

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? a. once a year b. whenever a new primary tooth erupts c. every 3 months d. every 6 months

d. every 6 months rationale: Dental examinations for a 4- to 5-year-old child should be conducted every 6 months. Every 3 months, once a year, and whenever a new primary tooth erupts are all incorrect.

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? a. uses facial expressions or gestures b. speaks at a normal rate and volume c. uses short sentences d. over articulates words

d. over articulates words rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker's face and lips. The nurse would watch to see that the AP avoided situations in which there is a glare or shadows on the client's field of vision. The nurse would also remind the AP to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The AP should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues.

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? a. oranges b. lettuce c. broccoli d. pinto beans

d. pinto beans rationale: Foods high in folic acid include beans (black, kidney, pinto, refried), peanuts, orange juice and oranges, asparagus, peas, broccoli, lettuce, and spinach. Pinto beans contain 294 mcg per 1-cup serving. An orange contains 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving.

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? a. the client has hyperlipidemia b the client is being treated for hypertension c. the client has type 2 diabetes mellitus d. the client is being treated for breast cancer

d. the client is being treated for breast cancer rationale: Combination oral contraceptives contain both estrogen and progestin and are contraindicated during pregnancy and for women who have (or have a history of) the following disorders: thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary-artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They are used with caution in women with diabetes mellitus, women who smoke heavily, women with risk factors for cardiovascular disease (hypertension, obesity, hyperlipidemia), and women anticipating elective surgery in which thrombosis might be expected.

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? a. the normal aging process increases the production of surfactant b. the normal aging process increases respiratory system compliance c. the normal aging process decreases the number of alveoli and increases the function of those remaining d. the normal aging process decreases an older clients ability to clear secretions

d. the normal aging process decreases an older clients ability to clear secretions rationale: Respiratory changes related to the normal aging process decrease an older adult's ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished.

Intramuscular phytonadione 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? a. rectus femoris muscle b. deltoid muscle c. gluteal muscle d. vastus lateralis muscle

d. vastus lateralis muscle rationale: Vitamin K is administered to the newborn infant in the hour after birth to help prevent hemorrhagic disease. The best site for intramuscular injection is the infant's vastus lateralis muscle, although, if necessary, the rectus femoris muscle may be used. The large vastus lateralis muscle is located away from the sciatic nerve, as well as the femoral artery and vein. The rectus femoris muscle is nearer these structures, and an injection there is more hazardous. The deltoid muscle is not used to administer intramuscular injections in the newborn infant. The gluteal muscles are never used until a child has been walking for at least a year. These muscles are poorly developed and dangerously near the sciatic nerve.

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

d. young adults ignore physical symptoms and postpone seeking health care rationale: Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help the nurse and client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and other chronic diseases. Young adults are not at risk for serious illness. The young adult may or may not be exposed to hazardous substances and may or may not be able to afford health insurance.