NCLEX PASSPOINT HEALTH PROMOTION & MAINTENANCE

A nurse is teaching caregivers how to select appropriate toys for their 10-month-old infant. Which statements by the caregivers indicate effective teaching? Select all that apply.

"We'll get the baby a push toy." "We'll get the baby some shape sorters." Explanation: Effective teaching is demonstrated if the caregivers say they will get the baby a push toy or shape sorters because at age 10 months, these toys promote development of an infant's gross and fine motor skills. These toys also aid cognitive development. Ride-on toys and simple puzzles are appropriate for toddlers, not infants. Rattles are appropriate for infants younger than 10 months of age.

When performing a physical examination on a neonate, the nurse notes low-set ears. What action should the nurse perform next?

Assess the neonate to determine if other apparent abnormalities are present. Explanation: Although low-set ears are an abnormal finding, the presence of this abnormality by itself isn't cause for immediate concern. The nurse should continue to assess the neonate to determine if other abnormalities are present. It's appropriate to note the abnormality in the medical record; however, it's even more important to continue the assessment. It's outside the scope of nursing practice to order a diagnostic test, such as an ultrasound, and there's no indication for this test.

The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse give the family on how to prevent sickle cell crisis?

Drink at least 2 quarts (1.9 liters) of fluids per day. Explanation: Increasing fluid intake and being well hydrated will help prevent cell stasis in the small vessels. Restricting fluids causes stasis of red blood cells and promotes obstruction and increases the chance of sickling with hypoxia and pain to the part that is involved. Clients with sickle cell disease should avoid exercising in cool temperatures or swimming in cold water. While contact sports are not recommended because of bleeding risks, they do not cause sickle crisis. Taking an anti-inflammatory medication before exercising does not prevent sickle cell crisis.

To meet the developmental needs of an 8-year-old child who is confined to home with osteomyelitis, what goal should the nurse include in the care plan?

Encourage the child to communicate with schoolmates. Explanation: Encouraging contact with schoolmates allows the school-age child to maintain and develop socialization with peers, an important developmental task of this age group. Although having family visits and interacting with the child are important, they do not meet the child's developmental needs. Talking to the child about his interests is important, but encouraging contact with schoolmates is crucial to maintain and develop socialization with peers.

The campus health nurse is caring for a client after she was sexually assaulted. Which of the following intervention would be most beneficial for this client?

Explore the client's strengths and resources with her. Explanation: The goal of crisis intervention is to support clients to resume pre-crisis levels of functioning. Variables in a client's recovery include support and access to resources. Suggesting courses in martial arts could be a strategy, but more important for the client's adjustment would be helping the client identify strengths and resources that could give her support. Assessing for coping should include all client activity, not only negative coping behaviors. Agreeing with the client that she should move on would be giving advice, a nontherapeutic technique.

A mother tells the nurse that she wants her 4-year-old to stop sucking her thumb. When developing the teaching plan, the nurse should suggest which intervention?

Get the child to agree to stop the thumb sucking. Explanation: A 4-year-old is old enough to be able to cooperate and stop the behavior. Therefore, the first step is to obtain the child's cooperation. When this has occurred, then the mother makes sure it is okay to remind the child when the behavior is viewed. Using a substance that does not taste good is not effective as the child may suck it off, and it does not promote health behavior. The mother also should be encouraged to praise the child when she sees her not engaging in the behavior; "time-out" is considered a punishment and does not promote the desired behavior.

A pregnant client's last menstrual period began on October 12. Using Naegele's rule, the nurse calculates the estimated date of delivery (EDD) as:

July 19. Explanation: Using Naegele's rule, the nurse calculates the client's EDD by adding 7 days to the first day of the last menstrual period (12 + 7 = 19) and subtracting 3 months from the month of the last menstrual period (October - 3 months = July). This results in an EDD of July 19.

A nurse is teaching a client about withdrawal from the excessive use of caffeine. What will the nurse include in the teaching? Select all that apply.

One of the first symptoms of withdrawal will be a headache. Drink fluids to help with the withdrawal. Nausea and muscle pain may occur with withdrawal. Explanation: The symptoms of caffeine withdrawal are headache, fatigue, drowsiness, irritability, and depression. Nausea and muscle pain can also occur. Drinking fluids during the withdrawal can prevent dehydration. Stopping the caffeine abruptly will not lessen symptoms.

Why should the nurse avoid palpating both carotid arteries at one time?

Palpating both arteries at one time may cause severe bradycardia. Explanation: The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

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

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

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse's priority intervention?

Place the client on her left side and apply oxygen. Explanation: An FHR below 70 beats/minute is considered severe fetal bradycardia, and immediate interventions are needed. The nurse would first apply oxygen after positioning the client on her left side. Positioning the client in the lithotomy position is not indicated. Although the provider would be notified of the status change in the client, the nurse would not wait on orders from the provider to act. Slowing the I.V. rate would reduce the circulating volume of blood and worsen the problem.

The nurse is caring for a recently circumcised newborn. Based on the progress note, what would be the most appropriate nursing intervention?2/10 0800Progress Note TabThree-day-old male, two days post-circumcision by Mogen clamp. Small amount of yellow-white exudate noted around glans. No bleeding or swelling noted. Axillary temp 36.4° C (97.5° F). Nursing eagerly, latching on well. Voided x4 post-circ.

Provide routine care to the circumcised area. Explanation: The yellow-white exudate is part of the granulation process and is a normal finding for a healing penis following circumcision. Routine vital signs and normal layering would be recommended for this neonate as this temperature is normal in a newborn. It is not necessary to increase monitoring or covering of the neonate. Pacifiers do soothe pain in the neonate; however, there is no indication in this progress note that the neonate is in pain.

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Refer the client to a healthcare provider for possible corrective lenses. Explanation: Visual acuity is usually measured with a Snellen chart. A client with 20/40 vision is able to read the same sized letters from 20 feet away as a person with "normal" vision would be able to read at 40 feet away. The client with 20/40 vision would be referred to a healthcare provider for the possible need for corrective lenses, as 20/20 vision is considered normal. The client would need to be evaluated by a healthcare provider prior to suggesting the purchase of corrective lenses for reading. In most jurisdictions, 20/40 vision qualifies for an unrestricted driver's license, so corrective lenses may not be required. However, the client must first see the healthcare provider before that can be determined.

The nurse is documenting assessment findings of the newborn. When assessing the neonate's head, the above is noted. Upon further examination, swelling is limited to below the scalp on the left side of the head. How does the nurse document this finding most accurately on the admission assessment to the nursery?

a cephalohematoma contained on the left side Explanation: The nurse notes a swelling, which does not cross the suture lines and is limited to the left side of the neonatal head. This is documented as a cephalohematoma. Caput succedaneum, a specific condition from the pressure of the birth, crosses the suture line and presents with diffuse edema. Identifying the condition is the best documentation. It is true that there is edema present but the documentation is inaccurate when it identifies the dorsal aspect. The documentation is also inaccurate in stating that there is bleeding on the brain.

A pregnant client at 26 weeks gestation walks a moderate distance to get to her prenatal class. When she gets to the class, she starts experiencing uterine cramping with no backache or bloody show. She is quite concerned about the cramping and asks the nurse what is happening. The most appropriate response from the nurse would be to

advise the client to rest and drink fluids. Explanation: Braxton Hicks contractions are irregular, generally painless uterine cramping and occur intermittently throughout the pregnancy often beginning around 16 weeks gestation. The client should rest and drink fluids to alleviate Braxton Hicks contractions. Lightening describes the effects when the fetus settles into the pelvis and cramping is not a sign. The client does not have the symptoms of preterm labor or miscarriage.

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise for 30 minutes. Which exercise frequency would meet the goals of planned exercise?

at least five times per week Explanation: Clients with diabetes must exercise at least 150 minutes per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Thirty minutes five times a week would meet the minimum amount of exercise recommended. Exercising once or even three times per week wouldn't achieve these goals. While exercising every day may be beneficial, it is not required to meet the 150 minutes per week recommendation.

To help promote independence in the area of feeding for a school-aged child in skeletal traction, the nurse should help the child choose which meal?

chicken nuggets with sauce, carrot sticks, apple slices, ice cream sandwich, and milk in a carton Explanation: To promote self-feeding, the nurse should provide the child with foods that can be eaten with the fingers or that do not spill easily. Fluids should be provided in containers with straws to prevent spills.

A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use?

helps lungs remain expanded after the initiation of breathing improving oxygenation Explanation: Surfactant works by reducing surface tension in the lung. It allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Improved oxygenation, as determined by arterial blood gases, is noted. Surfactant has not been shown to influence ciliary body maturation, regulate the neonate's breathing pattern, or lubricate the respiratory tract.

Which findings should the nurse expect to assess as normal skin changes in an older adult? Select all that apply.

diminished hair on scalp and pubic areas solar lentigo wrinkles xerosis Explanation: Skin changes associated with aging include diminished hair on scalp and pubic areas, solar lentigo (liver spots), wrinkles, and xerosis (dryness). Dusky rubor of the left lower extremity may indicate the individual has a venous stasis problem in the affected extremity and is generally associated with "unsuccessful aging." Yellow pigmentation of the skin that may be associated with liver inflammation is generally known as jaundice.

To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to demonstrate which skill?

lift head from prone position Explanation: A 1-month-old infant is usually able to lift the head from a prone position. The full-term infant with no complications has probably been able to do this since birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and holding a rattle are characteristics of a 4-month-old.

A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities?

obtaining a rubella titer on a woman who is planning to start a family Explanation: Obtaining a rubella titer is a primary prevention activity. Rubella may cause birth defects when contracted during the first 3 months of pregnancy. Identifying those who do not have an immunity and then providing the vaccine is a primary prevention activity. The remaining selections fall under secondary and tertiary prevention.

The nurse is caring for a child with a new diagnosis of diabetes. The nurse teaches blood glucose monitoring by allowing the child to practice checking the blood sugar of a toy bear dressed in a hospital gown. The nurse recognizes this approach to be appropriate for what age level?

preschool age (3 to 5 years) Explanation: Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play, and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation. Allow choices when possible.

A nurse is assessing a client with hepatitis A. The client reports having a poor appetite and the presence of food causes nausea. What should the nurse encourage the client to eat?

the majority of the calories in the morning during small frequent snacks Explanation: It is important to explain to the client who is having nausea that the majority of calories should be eaten in the morning because nausea most often occurs in the afternoon and evening. Small, frequent portions are best. Clients with viral hepatitis should select a diet high in calories because energy is required for healing. An intake of adequate carbohydrates can spare the protein because protein places an increased workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

A client who is 6 weeks' pregnant comes to the clinic for her first prenatal visit. What is the most immediate need for the nurse to address for this client?

the schedule of prenatal visits Explanation: To promote the health of the client and her fetus, the nurse should establish a regular schedule of prenatal visits. Prenatal visits are scheduled every 4 weeks up to 28 weeks, then every 2 weeks until 36 weeks. They are scheduled weekly after 37 weeks. Genetic testing isn't needed or scheduled unless the client reports a family history or some suspicion of genetic disease. These tests would be done during specific weeks of gestation. At 6 weeks' gestation, the uterus is not out of the pelvis, so the fundal height cannot be measured. Childbirth classes are generally offered to women closer to their delivery due date, although women may opt to enroll at any time.

A nurse is teaching the parents of a 7-year-old child about the use of protective restraints in the car to help avoid spinal cord injuries in car accidents. The child weighs 20 kg (44 lb). Which of the following information should the nurse emphasize in the teaching?

using a booster seat Explanation: A child must weigh 18 kg (40 lb) to move from a front-facing seat to a booster seat. The booster seat is used until the child outgrows it and the lap and shoulder belt fit correctly.

A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse at what time following the surgery?

when the sperm count reflects sterilization Explanation: After vasectomy, a sperm analysis will be performed every 4 to 6 weeks. A sperm-free analysis is necessary before the man can be considered sterile. Sperms gradually disappear from the ejaculate. Clients must be informed that conception is possible in the immediate post-vasectomy period.