NCLEX - PassPoint PN
A nurse is caring for a cleint with non-Hodgkin's lymphoma. Which statement indicates that the client diagnosed with non-Hodgkin's lymphoma needs further reinforcement from the education plan? "I know this all started when I felt that lump in my underarm." "Lymph tissue is in the spleen and bone and marrow." "Lymph tissue keeps the immune system in working condition." "If I stay healthy and eat right, I can cure this disease."
"If I stay healthy and eat right, I can cure this disease." Explanation: Non-Hodgkin's lymphoma cannot be cured by staying healthy. Medical treatments are prescribed to stop the disease progression. A lump can indicate a swollen lymph gland and maybe a sign of lymphoma. Lymph tissue is in the spleen and bone marrow. Lymph tissue makes lymphocytes and other immune system cells.
During admission data collection, the nurse asks the client about an advance directive. The client's family member states, "Why is this important when my mother is only here for a short stay?" Which response would the nurse give to help the client and family gain a better understanding of an advance directive? "You never know, something may happen even if it is a short stay." "It provides guidelines for making decisions in the event your mother is unable to make her medical decisions." "It makes sure that you do not create a scene in the case your mother becomes too sick to make medical decisions." "We ask everyone this question, no matter how long they stay."
"It provides guidelines for making decisions in the event your mother is unable to make her medical decisions." Explanation: An advance directive provides guidelines in the event the client becomes incapacitated and is unable to make his or her wishes known. The advance directive is asked of everyone but this response does not fully explain why it is asked. It is not used to prevent family members from making a scene in case the client is incapacitated. Telling the family member anything can happen is inappropriate and does not address the question.
A nurse is caring for a client with newly diagnosed diabetes mellitus. Which information should the nurse reinforce in education sessions about dietary management of diabetes? "Eating too much sugar causes diabetes." "Sugar is primarily found in desserts." "A client with diabetes should stop eating sugary foods." "Meals should be eaten at consistent times each day."
"Meals should be eaten at consistent times each day." Explanation: Maintaining a regular eating pattern to avoid hunger and the temptation to snack on high-calorie foods is crucial for clients with diabetes. A client with type 1 diabetes needs to adjust insulin doses according to food intake throughout the day. A client with type 2 diabetes should limit total calories but should not skip meals. Diabetes results from inadequate insulin or improper insulin utilization to control glucose, not from eating too much sugar. Various amounts and forms of sugar are available in different foods, not just desserts. Clients with diabetes should be taught to scrutinize all food labels for sugar content. Not all sugars should be removed from a client's diet. For example, natural sugars found in fruits should be eaten, whereas concentrated sweets should be avoided.
The nurse is reinforcing education to a parent of a child with cerebral palsy. Which statement indicates that the education has been successful? "My child's muscles will get stronger." "My child's condition will get progressively worse." "My child will have low intelligence." "My child will need continual therapy to maintain functioning."
"My child will need continual therapy to maintain functioning." Explanation: The child with cerebral palsy needs continual treatment and therapy to maintain or improve functioning. Without therapy, muscles will get progressively weaker and more spastic. Although some children with cerebral palsy have an intellectual disability, many have normal intelligence.
After a nurse reinforces education with an adolescent about syphilis, which statement by the adolescent indicates the need for further education? "The disease is divided into four stages: primary, secondary, latent, and tertiary." "Affected persons are most infectious during the first year." "Syphilis is easily treated with penicillin or doxycycline." "Syphilis is rarely transmitted sexually."
"Syphilis is rarely transmitted sexually." Explanation: About 95% of the cases of syphilis are transmitted sexually. There are four stages to syphilis, although some people may only experience the first three stages. Affected persons are most contagious in the first year of the disease. The drug of choice for treating syphilis is penicillin or doxycycline.
Which statement would the nurse include when reinforcing education for a parent about salmon patches (stork bites)? "They're benign and usually fade in adult life." "They're usually associated with syndromes of the neonate." "They can cause mild hypertrophy of the muscle associated with the lesion." "They're treatable with laser pulse surgery in late adolescence and adulthood."
"They're benign and usually fade in adult life." Explanation: Salmon patches occur over the back of the neck in 40% of neonates and are harmless, needing no intervention. Laser pulse surgery is not recommended for salmon patches because they typically fade on their own in adulthood. Portwine stains are associated with Sturge-Weber syndrome. Port-wine stains found on the face or extremities may be associated with soft tissue and bone hypertrophy.
A 2-year-old child's parent informs the nurse of a concern that the child may have attention deficit hyperactivity disorder (ADHD) because "my child has so much energy, doesn't pay attention for long, and is always getting into things." Which response by the nurse would be best? "This behavior is normal. The child is exploring and learning about the world." "You should talk to your pediatrician. You have definite concerns." "Keep intake of sugar and sugary treats to a minimum." "I'd suggest going to a child psychologist for evaluation."
"This behavior is normal. The child is exploring and learning about the world." Explanation: It's normal for a 2-year-old child to eagerly explore the environment for new sensory experiences. Talking to the pediatrician is inappropriate because the nurse is assuming a corrective, parental role toward the parent without addressing concerns. Restricting the child's intake of sugar and sugary treats is incorrect because the nurse is making assumptions and recommendations that don't relate to the parent's concerns. Suggesting evaluation by a psychologist reinforces the parent's fear that something is wrong with the child.
During a prenatal visit, the nurse measures a client's fundal height at 19 cm. The client asks what does this mean. How should the nurse respond? "This measurement indicates that the fetus has reached approximately 12 weeks." "This measurement indicates that the fetus has reached approximately 19 weeks." "This measurement indicates that the fetus has reached approximately 24 weeks." "This measurement indicates that the fetus has reached approximately 28 weeks."
"This measurement indicates that the fetus has reached approximately 19 weeks." Explanation: The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.
The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47 years. Following the American Cancer Society guidelines, what information would be the most important for the nurse to give the women? "All women should perform breast self-examination two to three times yearly." "Every woman should have a mammogram every 2 years beginning at age 40." "After the age of 50, you should have a hormonal receptor assay once yearly." "Women older than age 40 should have a mammogram and clinical examination every year."
"Women older than age 40 should have a mammogram and clinical examination every year." Explanation: The American Cancer Society guidelines state, "Women older than age 40 should have a mammogram annually and a clinical examination at least annually [not every 2 years]; all women should perform breast self-examination monthly [not annually]." The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.
The nurse is reinforcing education to an adolescent about sexually transmitted infection (STI). What statement made by the client indicates that further education is required? "You always know when you have gonorrhea." "The most common STI in kid's my age is chlamydia infection." "Most of the girls who have chlamydia don't even know it." "If you have symptoms of gonorrhea, they can show up a day or a couple of weeks after you got the infection to begin with."
"You always know when you have gonorrhea." Explanation: Gonorrhea can occur with or without symptoms. There are four main forms of the disease: asymptomatic, uncomplicated symptomatic, complicated symptomatic, and disseminated disease. All of the other statements by the adolescent about STIs are accurate.
A client is at her ideal weight when she conceives. During a prenatal visit 2 months later, she asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response? "You should gain less than 10 lb." "You should gain 10 to 15 lb." "You should gain 16 to 24 lb." "You should gain 24 to 32 lb."
"You should gain 24 to 32 lb." Explanation: For a client entering pregnancy in her ideal weight range, a gain of 24 to 32 lb (11 to 15 kg) is adequate to meet her needs and the needs of her fetus. Weight gain below the recommended range predisposes the client to complications during pregnancy, labor, and delivery.
A client arrives to the clinic with reports of a rash. The nurse observes the client and documents the lesion as a papule. What is the best way for the nurse to document this finding? 0.5-cm fluid filled lesion 0.5-cm red, flat pinpoint rash 0.5-cm elevated area 0.5-cm wheal
0.5-cm elevated area Explanation: Papules are elevated up to 0.5 cm, and nodules and tumors are masses elevated more than 0.5 cm. Erosions are characterized by loss of the epidermal layer. Macules and patches are nonpalpable, flat changes in skin color. Fluid-filled lesions are vesicles and pustules.
A client who retired six weeks ago, has been diagnosed with an adjustment disorder with mixed anxiety and depression. What can the nurse reinforce to help the client adapt well to the stress? Select all that apply. Remain hopeful about the past. Avoid social supports, such as friends and loved ones. Do something that gives you a sense of accomplishment. Find a support group geared toward your situation. Live a healthy lifestyle including a healthy diet and regular physical activity.
Do something that gives you a sense of accomplishment. Find a support group geared toward your situation. Live a healthy lifestyle including a healthy diet and regular physical activity. Explanation: A client with a sense of accomplishment, living a healthy lifestyle including a healthy diet and regular physical activity and having a support group will improve resilience and adaptation to the stress of retirement. The client needs to be hopeful about the future and stay connected to social support such as friends and family.
The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child is expected to be hospitalized for several weeks. When assisting with the plan of care, which nursing actions take into account the need to achieve developmental milestones in adolescence? Select all that apply. Encourage visitation of friends during hospitalization. Allow parents to make all stressful decisions for the adolescent. Provide for privacy, especially during ADLs and toileting. Encourage the parents to stay with the adolescent at all times. Arrange for in-hospital schooling so the child does not fall behind while hospitalized.
Encourage visitation of friends during hospitalization. Provide for privacy, especially during ADLs and toileting. Arrange for in-hospital schooling so the child does not fall behind while hospitalized. Explanation: According to the Erikson theory of personal development, an adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent tries to develop a sense of identity, and peer groups take on more importance. School performance is important. Adolescents often have an increased anxiety about missing school. When adolescents are hospitalized, they are separated from the peer group. Hospitalized adolescents fear invasion of privacy and altered body image. Adolescents want to be respected as individuals separate from the parents and need to be included in the decision-making process.
A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action? Make an appointment because the client needs to be evaluated. Explain that these are expected problems for the latter stages of pregnancy. Arrange for the client to be admitted to the birth center for delivery. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.
Explain that these are expected problems for the latter stages of pregnancy. Explanation: The nurse must distinguish between normal physiologic reports of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes related to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client does not need to be seen or admitted for delivery at this time.
A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be most appropriate? Tell the client that her milk is starting to come in because she's in labor. Complete a thorough breast examination, and document the results in the chart. Perform a culture on the discharge, and inform the client that she might have mastitis. Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy.
Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy. Explanation: After the fourth month of pregnancy, colostrum may be noticed. The breasts normally produce colostrum for the first few days after birth. Milk production begins 1 to 3 days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.
A 13-year-old boy visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first: send the child home to recover. inspect the child for uneven shoulder height or uneven hip height. arrange for the child to have spinal X-rays as soon as possible. ask the child's mother to take him to a physician immediately.
Inspect the child for uneven shoulder height or uneven hip height. Explanation: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent. The parent bears responsibility for seeking further medical care for the child.
A client is diagnosed with prehypertension. Which of the following would most likely be included in the client's treatment plan? Diuretics Lifestyle modification instructions Beta-adrenergic blockers Angiotensin-converting enzyme (ACE) inhibitors
Lifestyle modification instructions Explanation: Prehypertension signals the need for teaching about lifestyle modifications to prevent hypertension. Lifestyle modifications may include dietary changes, adopting relaxation techniques, regular exercise, smoking cessation, limiting intake of alcohol, and restricting sodium and saturated fat intake. Diuretics, beta-adrenergic blockers, and ACE inhibitors are used to treat hypertension.
A 4-year-old girl has a urinary tract infection (UTI). When teaching the parents how to help her avoid recurrent UTIs, the nurse should emphasize which preventive measure? Wiping her perineum from back to front after she uses the toilet Administering prophylactic antibiotics Giving her a warm bath for 15 minutes daily Making sure she avoids bubble baths
Making sure she avoids bubble baths Explanation: The child should avoid bubble baths because oils in the bubble bath preparation may irritate the urethra, contributing to UTIs. Girls and women should wipe the perineum from front to back, not back to front, to avoid contaminating the urinary tract with fecal bacteria. Although antibiotics are used to treat UTIs, they aren't given prophylactically. No evidence suggests that warm baths help prevent UTIs.
When planning a program to educate adolescents about acquired immunodeficiency syndrome (AIDS), which action might lead to better acceptance of the program? Survey the community to evaluate the level of education. Obtain peer educators to provide information about AIDS. Set up clinics in community centers and supply condoms readily. Invite health care providers to host workshops in community centers.
Obtain peer educators to provide information about AIDS. Explanation: Peer education programs have shown that teens are more likely to pose questions to peer educators than to adults, and that peer education can change personal attitudes and the perception of the risk of HIV infection. The other approaches would be helpful but wouldn't necessarily make the outreach program more successful.
A nurse is caring for a client with candidiasis. What information should the nurse obtain from the client? Select all that apply. Recent antibiotic use Menopause Use of corticosteroids Use of oral contraceptives Use of over the counter herbal medications
Recent antibiotic use Use of corticosteroids Use of oral contraceptives Explanation: The use of antibiotics increases the risk of candidiasis. Small numbers of the fungus Candida albicans commonly inhabit the vagina. Because corticosteroids decrease host defense, they increase the risk of candidiasis. Candidiasis is rare before menarche and after menopause. The use of hormonal contraceptives increases the risk of candidiasis. OTC herbal medications do not increase the incidence of candidiasis.
An older adult client who has chronic respiratory disease comes to the clinic for a 6- month check. The nurse informs the client that it's time for the pneumococcal and flu vaccines. What would be the nurse's best explanation to the client for these injections? All clients are recommended to have these vaccines. These vaccines produce bronchodilation and improve oxygenation. These vaccines help reduce the tachypnea these clients experience. Respiratory infections can cause severe hypoxia and possibly death in clients with chronic respiratory diseases.
Respiratory infections can cause severe hypoxia and possibly death in clients with chronic respiratory diseases. Explanation: It's highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause respiratory failure, and these clients may need to be intubated and mechanically ventilated. The vaccines have no effect on respiratory rate or bronchodilation.
The nurse is assisting with the discharge of a client with acute pyelonephritis. What should the nurse be sure to include in the client instructions? Avoid taking any dairy products. Return for follow-up urine cultures. Stop taking the prescribed antibiotics when the symptoms subside. Recurrence is unlikely because of treatment with antibiotics.
Return for follow-up urine cultures. Explanation: The client needs to return for follow-up urine cultures because bacteriuria may be present but may not produce symptoms. Intake of dairy products will not contribute to pyelonephritis. Antibiotics must be taken for the full course of therapy regardless of symptoms. Pyelonephritis commonly recurs as a relapse or new infection, usually within 2 weeks of completing therapy.
When talking to the parents of a neonate with congenital hypothyroidism, the nurse should encourage which action? Seek professional genetic counseling. Retrace the family tree for others born with this condition. Talk to relatives who have gone through a similar experience. Wait until the neonate is 1 year of age before obtaining counseling.
Seek professional genetic counseling. Explanation: Seeking professional genetic counseling is the best option for parents who have a neonate with a genetic disorder, such as congenital hypothyroidism. Retracing the family tree and talking to relatives will not help the parents become better educated about the disorder. Education about the disorder should occur as soon as the parents are ready, so they will understand the genetic implications for future children.
The nurse is caring for a preschool child just diagnosed with impetigo. What is the most important action the nurse should take to prevent the spread of impetigo to others? Cover the area. Isolate the child at home. Apply an antibacterial ointment. Teach child and family good handwashing techniques.
Teach child and family good handwashing techniques. Explanation: Handwashing is the most important action that a nurse or client can take to prevent the spread of infection. Covering the area or applying an antibacterial ointment does not stop the spread of infection, nor does isolating the child.
The nurse is caring for a client with human immunodeficiency viirus (HIV) and reinforcing education regarding disease prevention. What is the importance of disease prevention for this client? The client's personal behavior has a direct link to the maintenance of health. The client is only infected with the virus and does not have to be concerned with illness at this time. If the client maintains optimal health, acquired immune deficiency will not occur. The external environment affects the outcomes of most disease processes.
The client's personal behavior has a direct link to the maintenance of health. Explanation: Linking health and personal behavior is extremely important to disease prevention, especially when the client is immunocompromised. By promoting healthy behaviors, the client can delay disease progression so the client should be concerned with disease progression. Even with the maintenance of optimal health, the ability to develop AIDS is great. The external environment does not effect most disease process but may have some contributing factors.
The parent of an 8-year-old client tells the nurse that when the child plays with other children, the child does not seem to interact with them, but simply plays alongside. What does the nurse determine about the child? This is solitary play typical of infants, not preschool children. This is a parallel play typical of toddlers, not preschool children. This is associative play typical of preschool children, not school-aged children. This is cooperative play typical of adolescents, not school-aged children.
This is a parallel play typical of toddlers, not preschool children. Explanation: Playing alongside, but not interacting with the other child, is an example of parallel play, which is typical of toddlers. School-aged children typically engage in cooperative play where they follow organized rules and have a defined leader and followers. Solitary play, typical of infants, is when the child is focused on own activity, even when playing in the presence of other children. Associative play where children play together, but without organization or leaders and followers, is typical of preschool play.
A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. Which information should be provided to the school? These students are too young to screen; instead, older students should be screened. These students are too old to screen and will no longer benefit from screening for scoliosis. Scoliosis screening requires sophisticated equipment and cannot be done in school. This is an appropriate request and arrangements will be made as soon as possible.
This is an appropriate request and arrangements will be made as soon as possible. Explanation: Screening for scoliosis should begin at age 8 and should be performed yearly thereafter. Screening for scoliosis involves inspection of the spine and use of a scoliometer, both of which can be done in a school setting.
An adult who has never had mumps reports that he was just notified that a child of a family with whom he stayed recently has been diagnosed with mumps. Which treatment should the man receive? IV antibiotics ice packs to the scrotum application of a scrotal support administration of gamma globulin
administration of gamma globulin Explanation: Gamma globulin provides passive immunity to mumps. Antibiotic therapy is used in the treatment of bacterial orchitis. Ice and a scrotal support are used as comfort measures in the treatment of orchitis.
A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: as the infant plays. as the infant sleeps. as the mother feeds the infant. as the mother rocks the infant.
as the mother feeds the infant. Explanation: The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping doesn't provide an opportunity for mother-infant interaction. Although playing and rocking may provide clues about mother-infant interaction, they aren't the best activities to assess. During playing, for instance, the mother may interact with the infant at a distance. Rocking promotes closeness but not interaction; the mother can rock the infant while talking to someone else or staring off into the distance.
The nurse is caring for a neonate whose mother is infected with hepatitis B. The nurse would inform the mother that her child will receive which treatment? hepatitis B vaccine at birth and age 1 month hepatitis B immune globulin at birth; no hepatitis B vaccine hepatitis B immune globulin within 48 hours of birth, and hepatitis B vaccine at age 1 month hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months
hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months Explanation: Hepatitis B immune globulin should be given as soon as possible after birth but within 12 hours. Neonates should also receive hepatitis B vaccine at regularly scheduled intervals. This sequence of care is considered superior to the other treatment options.
A nurse is caring for a neonate and is using measures to help maintain the neonate's temperature. Which intervention would be most effective in helping to prevent evaporative heat loss? administering warm oxygen controlling the drafts in the room immediately drying the neonate placing the neonate on a warm, dry towel
immediately drying the neonate Explanation: Immediately drying the neonate decreases evaporative heat loss from his moist body from birth. Placing the neonate on a warm, dry towel decreases heat loss through conduction. Controlling the drafts in the room and administering warm oxygen help reduce heat loss through convection.
During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for: muscle weakness. joint abnormalities. painful subcutaneous nodules. gait disturbances.
joint abnormalities. Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Nonarticular connective tissue, such as collagen in the lungs, heart, muscles, vessels, pleura, and tendons, may be involved diffusely. Vasculitis may affect the eyes, nervous system, and skin, causing thrombosis and ischemia. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.
A client in the fifth month of pregnancy is having a routine clinic visit. When gathering data from the client, the nurse would be alert for which common second trimester condition? mastitis metabolic alkalosis physiologic anemia respiratory acidosis
physiologic anemia Explanation: Hemoglobin level and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. The result is physiologic anemia. Mastitis is an infection in the breast characterized by a swollen, tender breast and flulike symptoms. This condition is most commonly seen in breast-feeding clients. Alterations in acid-base balance during pregnancy result in a state of respiratory alkalosis, compensated by mild metabolic acidosis.
The nurse is obtaining data from a new client in the cardiovascular clinic. When asking about childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? croup rheumatic fever severe staphylococcal infection medullary sponge kidney
rheumatic fever Explanation: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup—a severe upper airway inflammation and obstruction that typically strikes children ages 3 months and 3 years—may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn't damage heart structures.
When caring for an older adult client, the nurse should expect to find which normal age-related changes that may affect client education? reduced intelligence electrolyte imbalances slowed reaction time increased vein elasticity
slowed reaction time Explanation: Slowed reaction time is a normal age-related change in older adult clients. Although the client's intelligence should remain intact, aging may slow learning speed. Electrolyte imbalances are abnormal findings in clients of any age. With age, vein elasticity usually decreases, not increases.
The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit: consistent table manners. an increased appetite. strong food preferences. a preference for eating alone.
strong food preferences. Explanation: A toddler typically exhibits strong food preferences, eating one type of food for several days and excluding others. A toddler can't be expected to use consistent table manners. Generally, the appetite decreases during the toddler stage because of a slowed growth rate. A toddler typically enjoys socializing during meals and often imitates others.
The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as: 50 ml 100 ml 150 ml 200 ml
100 ml Explanation: One gram of weight is approximately equivalent to 1 ml of fluid. Therefore, the blood loss estimate for a perineal pad weighing 100 g would be approximately 100 ml.
Which of the following is the recommended immunization schedule for diphtheria, tetanus, acellular pertussis (DTaP)? Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years Birth, 3 months, 6 months, 12 months, and 4 to 6 years
2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years Explanation: According to the American Academy of Pediatrics, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school). The other options are incorrect.
A client is 33 weeks' pregnant and has had diabetes since age 21. When checking the fasting blood glucose level, which value would indicate the client's disease is controlled? 45 mg/dL (2.5 mmol/L) 85 mg/dL (4.7 mmol/L) 120 mg/dL (6.67 mmol/L) 136 mg/dL (7.56 mmol/L)
85 mg/dL (4.7 mmol/L) Explanation: The recommended fasting blood glucose level in the pregnant client with diabetes is 60 to 95 mg/dL (3.33 to 5.28 mmol/L). A fasting blood glucose level of 45 mg/dL (2.5 mmol/L) is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dL (6.67 mmol/L) is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dL (7.56 mmol/L) in a pregnant client indicates hyperglycemia.
An elderly client, age 75, is admitted to the health care setting. In what manner will the nurse modify this client's data collection? Shortening it Talking in a loud voice Addressing the client by his first name Allowing extra time for this task
Allowing extra time for this task Explanation: When collecting data on an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, should address the client respectfully rather than by his or her first name, and should give simple instructions. Talking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.
A primigravid client is admitted to the labor and delivery area in the early first stage of labor. She is breathing with each contraction. Which action taken by the nurse helps the client deal with the pain of labor? Assist the client to a supine position with the legs in the stirrup. Assist the client to practice Kegel exercise. Assist the client in performing effleurage. Encourage client to push with each contraction.
Assist the client in performing effleurage. Explanation: Effleurage, gentle massage of the abdomen and thigh, is soothing to the mother during labor. Kegel exercises tighten the pelvic floor muscles, needed after birth and not during labor. Pushing before the cervix is fully dilated can cause swelling and tearing of the cervix. Supine position can cause compression of the abdominal vessels, leading to hypotension.
When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction? Avoid using cornstarch on the feet. Avoid wearing canvas shoes. Avoid using a nail clipper to cut toenails. Avoid wearing cotton socks.
Avoid wearing canvas shoes. Explanation: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton socks and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.
A client in the third trimester of pregnancy is having contractions 5 minutes apart that began suddenly. The nurse identifies that it is the client's seventh month. The client is admitted directly to the obstetrics department. Which intervention has priority? Call the obstetrician. Time the contractions. Check fetal heart tones. Call the client's spouse.
Check fetal heart tones. Explanation: The nurse should check fetal heart tones and assess the client's vital signs. The client should be placed on a monitor to check contractions and for continuous fetal monitoring. The obstetrician and spouse should be notified as soon as possible.
The nurse is planning sex and contraceptive education for adolescents. Which factor should the nurse consider? Neither sexual activity nor contraception requires planning. Most teenagers today are knowledgeable about reproduction. Most teenagers use pregnancy as a way to rebel against their parents. Most teenagers are open about contraception, but inconsistently use birth control.
Most teenagers are open about contraception, but inconsistently use birth control. Explanation: Adolescents receive most of their information on reproduction and sexuality from their peers, who generally do not have correct information. Teenagers generally become pregnant because they fail to use birth control for reasons other than rebelling against their parents. Contraception should always be part of sex education and requires planning. Most teenagers today are open about discussing contraception and sexuality, but they may get caught up in the moment of sexuality and forget about birth control measures.
A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? Up to 10 Up to 15 Up to 20 Up to 32
Up to 20 Explanation: A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13.
The nurse is preparing to administer an intramuscular (I.M.) injection to a 6-month-old infant. Which appropriate site would the nurse inject the infant? Vastus lateralis muscle Ventrogluteal area Deltoid muscle Gluteus maximus muscle
Vastus lateralis muscle Explanation: The nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis muscle. The ventrogluteal area should be used only after the child has been walking for about a year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.
A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she: express milk manually. take antilactation drugs. take hot showers. wear a supportive, well-fitting brassiere.
wear a supportive, well-fitting brassiere. Explanation: A proper brassiere helps prevent breast engorgement by providing support and acting as a barrier to breast stimulation. Ice pack application helps reduce swelling. Antilactation drugs are no longer recommended because a rebound effect may occur after they're discontinued; also, they're expensive and may cause adverse effects. Manual milk expression and hot showers stimulate the breasts, triggering milk production and prolonging the discomfort of engorgement.
A primigravida client is 16 weeks pregnant. Which client instruction would be most important to reinforce in order to prevent toxoplasmosis? cooking meats thoroughly keeping dogs outside washing all vegetables having antibody titers routinely drawn
cooking meats thoroughly Explanation: Undercooked fresh meats that contain cysts with toxoplasmosis can cause infection. Cats, not dogs, carry toxoplasmosis. Toxoplasmosis is not carried on vegetables. Antibody titers do not prevent toxoplasmosis.
The nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: "Have you ever had osteomyelitis?" "Do you have any cats at home?" "Do you have any birds at home?" "Have you recently had a rubeola vaccination?"
"Do you have any cats at home?" Explanation: TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus, agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.
A nurse is reinforcing education with a client who has hypertension. The nurse recognizes that the education has been effective when the client makes which statement? "I shouldn't adjust my medication without my health care provider's advice." "I can stop taking my medication when I no longer have headaches." "I should stop taking my medication if I have adverse effects." "I only have to take the medication when I feel bad."
"I shouldn't adjust my medication without my health care provider's advice." Explanation: Medication for blood pressure control must not be adjusted or stopped without primary care provider approval. Any medication changes require close monitoring of the client. Medication must be continued on a regular schedule, or the client's blood pressure will rise. Therefore, client teaching has been ineffective when the client states that (a) the medication may be discontinued when the headaches cease, or (b) medication should be taken when the client feels bad. If serious adverse effects occur, the client should notify the health care provider. Other medications can be substituted without the adverse effects.
A nurse participating in planning care for a client who is in labor expects to monitor the client's blood pressure frequently. Why is this action important? Decreased blood pressure is a sign of maternal pain. Alterations in cardiovascular function affect the fetus. Blood pressure decreases at the peak of each contraction. Decreased blood pressure is the first sign of preeclampsia.
Alterations in cardiovascular function affect the fetus. Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should frequently monitor the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, maternal blood pressure usually increases. Similarly, preeclampsia causes blood pressure to increase, not decrease.Alterations in cardiovascular function affect the fetus. Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should frequently monitor the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, maternal blood pressure usually increases. Similarly, preeclampsia causes blood pressure to increase, not decrease.
A child is to receive phenytoin, 5 mg/kg by mouth each day. When teaching the parents about the medication regimen, the nurse should use which approach? Conduct brief education sessions, provide written materials during each visit, and repeat information as appropriate. Ask the parents to spend an entire day at the facility so they can learn every detail about their child's care. Call the parents at home and explain everything, allowing time for them to ask questions. Send the parents the drug packaging insert so they can become familiar with the medication.
Conduct brief education sessions, provide written materials during each visit, and repeat information as appropriate. Explanation: Effective teaching methods include providing simple instructions in short sessions, providing written materials, repeating information, and allowing time for questions. The other options are ineffective teaching strategies that may be overwhelming for the parents and frustrating for the nurse.
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover: cancerous lumps. areas of thickness or fullness. changes from previous self-examinations. fibrocystic masses.
changes from previous self-examinations. Explanation: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.
A child admitted with pneumonia has a history of cystic fibrosis (CF). Which statement made by the parents best demonstrates an understanding of cystic fibrosis? It is a genetic disorder carried on the X chromosome. Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. In cystic fibrosis only one defective gene or set of genes is passed by one parent. It is a chronic disease, but it is not progressive.
Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. Explanation: Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. In recessive disorders such as cystic fibrosis, both parents must pass the defective gene or set of genes to the child. Dominant disorders are characterized by only one defective gene or set of genes passed by one parent. Sex-linked genetic disorders are carried on the X chromosome. It is a chronic disease and is progressive.
How can breast cancer prevention programs best serve women who are at risk and come from lower socioeconomic backgrounds? Provide access to health insurance. Increase support services. Increase access to health care. Develop screening and educational programs.
Develop screening and educational programs. Explanation: Breast cancer prevention programs can best serve at-risk women from lower socioeconomic backgrounds by developing screening and educational programs tailored to their needs. Without increasing educational awareness and screening, improving access to insurance, heath care, and support services won't help these women. According to the National Breast and Cervical Cancer Early Detection Program, research shows that without better screening and education programs, women with low incomes are 3 to 7 times more likely to die from cancer than women with higher incomes.
During a clinic visit, the nurse notes that a 3-year-old preschooler, who measured 27 inches at the age of 2, now measures 29.5 inches. Based on the preschooler's measurement, how would the nurse proceed? Notify the health care provider. Document the finding. Wait 5 minutes and measure the toddler again. Explain to the caregiver that the toddler is not growing fast enough.
Document the finding. Explanation: The preschooler grows 1½ to 2½ inches/year, so the nurse should document the finding. Because the preschooler's measurement is in the expected range, there is no need to notify the health care provider or wait 5 minutes and measure the client again. It is inappropriate to explain to the caregiver that the preschooler is not growing fast enough.
The nurse is reinforcing nutritional information with a client with a leukocyte (WBC) count of 2,500/µL (2.50 × 109/L). What food should the nurse be sure to have the client avoid? white bread raw carrot sticks stewed apples well-done steak
raw carrot sticks Explanation: The normal leukocyte (WBC) is 4.500 /(4.50 × 109/L) to 11,000/ (11.00 × 109/L). A WBC count of 2,500/ (2.50 × 109/L) is low, making the client prone to infection. A low-bacteria diet is indicated, which excludes raw fruits and vegetables.
A client who has just given birth to a full-term neonate is handed the neonate by the nurse. Which factor is most likely to promote attachment between parents and their neonate? verbalization of desire by the parents to bond with the neonate completion of parental education about the importance of bonding sustained physical contact with the neonate immediately after birth history of attachment with previous birth experiences
sustained physical contact with the neonate immediately after birth Explanation: The neonate's first period of reactivity, which occurs in the first hour after birth, is the ideal time for attachment. During this period, the parents can touch, hold, talk to, examine, and feed the neonate. Although parental desire and education can contribute to effective attachment, the parents must ideally make early physical contact for attachment to occur. Attachment during previous births may aid in attachment now, but early interaction with this neonate is still necessary.
Four children, each 6 months of age, arrive at the clinic for diphtheria-pertussis-tetanus (DPT) immunization. Which child can safely be immunized at this time? the child with a temperature of 103° F (39.4° C) the child with a runny nose and cough the child taking prednisone for the treatment of leukemia the child with difficulty breathing after the last immunization
the child with a runny nose and cough Explanation: Children with cold symptoms can safely receive DPT immunization. Children with a temperature more than 102° F (38.9° C), serious reactions to previous immunizations, or those receiving immunosuppressive therapy shouldn't receive DPT immunization.
When presenting an informational series on infant safety, which appropriate development milestone for the 4-month-old infant would the nurse stress could jeopardize the infant's safety? responds readily to sound grabs feet and pulls to the mouth turns from abdomen to back drops objects to pick up another one
turns from abdomen to back Explanation: The ability to turn from abdomen to back puts the infant at risk for falling: parents must be careful not to leave the infant unattended with the crib's side rails down, on the sofa, or on the changing diaper table. The other three responses are not additional risks for the infant.
