NCLEX review Silversteri - Health promotion and maintenance first 120 questions

Cholestyramine

1. Cholestyramine is a bile acid sequestrant used to lower the cholesterol level, and client compliance is a problem because of its taste and palatability. 2. The use of flavored products or fruit juices can improve the taste. 3. Some side effects of bile acid sequestrants include *constipation* and decreased *vitamin absorption*.

Mg ++ contributes to ________

1. Clients, who have problems with severe *constipation* 2. May abuse *laxatives* that 3. Contain magnesium such as *magnesium hydroxide*.

1. Garlic ? 2. Eczema 4. Migraines 3. Insommia

1. Garlic used to treat hyperlipidemia and hypertension. 2. eczema is evening primrose. 3. Insomnia has been treated with both valerian root and chamomile. 4. Migraines have been treated with feverfew.

The client who received a kidney transplant is taking azathioprine, and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for further teaching?

1. I need to watch for signs of infection." 2. "I need to discontinue the medication after 14 days of use." 3. "I can take the medication with meals to minimize nausea." 4. "I need to call the primary health care provider (PHCP) if more than one dose is missed." answer : 2

71.Lochia

1. Lochia, the uterine discharge present after birth, initially is *bright red* and may contain *small clots*. 2. During the 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. 3. After that time the lochial flow should steadily decrease and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, the remaining options are incorrect.

THird trimaster leg cramps A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps,

1. leg cramps may be a --result of *compression of the nerves* supplying the legs because of the enlarging uterus, ---a reduced *level of diffusible serum* *calcium*, ---an increase in *serum phosphorus*, or ---the *presence of thrombophlebitis*. 2. In the pregnant client who complains of leg cramps, the nurse should first check for *signs of thrombophlebitis* and *notify the registered nurse*.

The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider? 1. A repeat rubella titer in 2 weeks 2. Administration of a subcutaneous rubella virus vaccine 3. Administration of a subcutaneous rubella virus vaccine for the newborn 4. Counseling to the mother and informing the mother that this is a normal titer

2 Rationale: A blood sample for rubella titer is done on all women in the antepartum or postpartum period. A postpartum woman with a titer of 1.8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II) following the birth of her baby. This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine.

Urine output

1500-2000 ml/day

The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client? 1. Expect the baby to move at least 35 times in 3 hours. 2. Lie on the stomach when preparing to count the fetal movement. 3. Schedule the counting periods in the morning when the fetal movement is highest. 4. Contact the primary health care provider if the baby's movements are fewer than 10 times in 2 hours.

4 Rationale: Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes three times a day. The woman should lie on her left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement, which is lower in the morning and higher in the evening.

The nurse has reinforced instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client makes which statement? 1. "Stop and start the stream of urine several times during a voiding." 2. "Tighten perineal muscles for up to 10 seconds several times a day." 3. "Tighten perineal muscles for up to 5 minutes three or four times a day." 4. "Begin voiding and then stop the stream, holding residual urine for an hour."

4. Rationale: Kegel exercises strengthen the perineal floor and are useful to prevent and manage cystocele, rectocele, and enterocele. There are several acceptable ways to perform Kegel exercises. These involve starting and stopping the flow of urine either once for up to 5 minutes, or several times during a single voiding for about 5 seconds. Because the muscles that control urination also are involved in defecation, these exercises also can be done once during defecation. Otherwise, they may be done by holding perineal muscles taut for up to 10 seconds several times a day, or for 5 minutes three or four times a day. Option 1 is not a correct method for performing Kegel exercises. Residual urine should not be held in the bladder for lengthy periods because it could promote urinary tract infection.

Rubeolla care

A nursing consideration in rubeola is 1. eye care. 1-1. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. 2. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome. 3. Warm baths and the sun will aggravate itching. In addition, the child needs to rest.

Erikson, infant's need

According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, the infant will not learn how to control the environment. -Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others. -Therefore, the remaining options are incorrect.

Folic acid

Folic acid (folate) helps prevent neural tube birth defects; it is found in green, leafy vegetables; liver, beef, and fish; legumes; and grapefruit and oranges. Peanuts are high in protein and niacin. Milk is high in calcium and vitamin D. Egg yolks are high in vitamin A, iron, and cholesterol.

The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?

Selecting shoes that have firm nonskid soles 2. Applying nonskid strips on areas that get wet 3. Installing telephones in several rooms of the house 4. Maintaining body weight at or above minimum recommended levels ans: 4 Maintaining body weight at or above minimum recommended levels is a primary prevention measure. Additional prevention measures include achieving optimal calcium intake, performing regular exercise, avoiding smoking and alcohol consumption, avoiding a high-sodium and high-protein diet, and consuming adequate amounts of vitamin D. The other prevention measures are secondary and not

Decrease otitis media

TO decrease the risk of recurrent otitis media, 1. Parents should be encouraged to *breastfeed* during infancy, 2. *discontinue bottle-feeding* as soon as possible, 3. feed the infant in an *upright position*, & avoid giving the infant a bottle in bed. 4. Parents should be told *not to smoke* in the child's presence because passive smoking increases the incidence of otitis media.

EYE testing 1. visual field - 2. tonometry 3. ishihara 4. flashlight

The 1. confrontational method of eye testing is used to examine *visual fields or peripheral* vision. 2. Tonometry is used to check for glaucoma. 3. An Ishihara chart is used to check color vision. 4. A flashlight is used to test pupillary response to light.

Fourth stage with epidural what do you lose ?

The fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body begins to readjust and relax. An epidural may lead to loss of bladder sensation and resulting rapid bladder filling. The remaining options relate to earlier stages in the labor process. bladder function lost

colon cancer risk factors

The incidence of colorectal cancer increases with age. 1. Colorectal cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. 2. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10 years' duration. 3. A diet high in fiber is considered protective again colorectal cancer.

How do Warfarin ( Coumadin ) and Heparin work?

Vitamin K controls the creation of these cofactors in your liver, and warfarin reduces clotting in your blood by preventing vitamin K from working correctly. Heparin also works by preventing certain cofactors, namely thrombin and fibrin, from working correctly.

Fundal ht measuring

When measuring fundal height, the client lies in a supine position, and the nurse places a wedge under the right hip. This position will assist in preventing supine hypotension. Standing, right lateral or prone positions are incorrect client positions for measuring fundal height.

BCG given why to who?

1. The BCG vaccine is used mainly for children with a negative chest x-ray and skin test results 2. who have had repeated exposures to TB and for asymptomatic HIV-infected children who are at increased risk for developing TB.

The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statement?

"Here's the Medic-Alert bracelet I obtained." 2. "I should take my medications an hour before mealtime." 3. "Resting in a sauna will be a relaxing form of activity." 4. "I've made arrangements to get a portable resuscitation bag and home suction equipment." ans: 3

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the school children. Which statement, if made by a parent, indicates a need for further teaching regarding this communicable disease?

"Small blue-white spots with a red base may appear in the mouth." 2. "The rash usually begins centrally and spreads downward to the limbs." 3. "Respiratory symptoms such as a very runny nose, cough, and fever occur before the development of a rash." 4. "The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears." answer : 4 Options 1, 2, and 3 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Koplik spots. Option 4 describes the incubation period for rubella, not rubeola.

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply.

"The preembryonic period is the period of time before conception." 2. "The preembryonic period is the longest period of fetal development." 3. "The preembryonic period is the first 2 weeks of fetal development following conception." 4. "The preembryonic stage is the most critical time in the development of the organ systems and the main external features." 5. "The preembryonic period is the fetal development period from the beginning of the third week through the eighth week after conception." 6. "The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers." 3.6

Positive signs of

. Positive signs of pregnancy -include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a -nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; -and an outline of the fetus via radiography or ultrasound.

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement? 1. "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement." 2. "I should drink 8 to 12 glasses of liquid a day, and I can count the coffee that I drink." 3. "I should drink 8 to 12 glasses of liquid a day, and I can count the tea, fruit juices, or milk that I drink." 4. "I should drink 8 to 12 glasses of liquid a day, and I can count the carbonated soft drinks that I consume."

1 Rationale: The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation: 8 to 12 glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages.

Fundal height

1 At 14 to 16 weeks' gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. 2. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and at term, the fundus is at the xiphoid process.

The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitudes? Select all that apply. 1. Alertness 2. Irritability 3. Excitement 4. Seriousness 5. Helplessness

1,3 Rationale: In early labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth and she is often alert and talkative related to what she is experiencing. Options 2, 4, and 5 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.

The nurse is reinforcing instructions to a client about the types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? Select all that apply.

1. Milk 2. Soda 3. Prune juice 4. Apple juice 5. Cranberry juice answer : 3.4.5

1. Anal : 2. Oral : 3. Phallic:

1. *Anal stage*: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces. 2. *Oral stage* : Self-gratification relates to the *oral stage*. Tapering off of conscious biological and sexual urges relates to the latency period. 3. *Phallic stage*: Association with pleasurable and conflicting feelings about genital organs relates to the *phallic stage*.

cyclosporine

1. A compound present in grapefruit juice inhibits metabolism of cyclosporine. 2. As a result, the consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity. Grapefruit juice needs to be avoided. Red meats; orange juice; and green, leafy vegetables are acceptable to consume.

1. Separation anxiety begins ? 2. Separation anxiety peaks ? 3. Separation anxity ends ?

1. Babies can show signs of separation anxiety as early as *6 or 7 months*, 2. It peaks between *10 to 18 months* and 3. Eases up by *2 years*.

High potassium food

1. Bread and butter, 2. carrots and peas, and 3. peppers and onions are relatively low sources of potassium.

TSE

1. The TSE is recommended after *a warm bath or shower* when the scrotal skin is relaxed. 2. The client should set up a schedule of performing *TSE* the *same day* each month in order not to forget. 3. The client should *stand* to examine the testicles. 4. Using *both hands*, with the fingers under the scrotum and the *thumbs on top*, the client should gently *roll* the testicles, feeling for any lumps. 5. The TSE should be performed *monthly*.

Bladder cancer

1. The incidence of bladder cancer is greater among *men than among women*, 2. It affects the *white population* twice as often as the black population. 3. Age over *40, environmental exposure* to certain chemicals, and cigarettes especially are associated with the incidence of bladder cancer.

The clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to the child. The nurse should administer this vaccine by which method?

1.intramuscularly in the deltoid muscle 2. Subcutaneously in the gluteal muscle 3. Subcutaneously in the outer aspect of the upper arm 4. Intramuscularly in the anterolateral aspect of the thigh answer : 3

The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure? 1. "I should retract the foreskin and clean the penis every time I change the diaper." 2. "I need to retract the foreskin and clean the penis every time I give my newborn a bath." 3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

3 Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, adhesions can develop. It is best to allow separation of the foreskin to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning once a week.

The client is informed that she is now in the second stage of labor, the descent phase. Which observations should the nurse make to support this stage of labor? Select all that apply. 1. Following directions readily 2. Talking about labor experience 3. Bearing down with contractions 4. Making expiratory vocalizations 5. Changing body positions frequently

3,4,5 Rationale: As the fetus's head moves through the vaginal canal (second stage, descent phase), the maternal behaviors noted include increased urge to push, grunting sounds or expiratory vocalization, frequent position changes, and altered respiratory patterns. Early in labor (stage 1) the client may be talkative and will readily follow directions.

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks? 1. 6 to 8 2. 8 to 10 3. 12 to 16 4. 20 to 22

3. Rationale: By the end of the *twelfth week*, the fetal gender can be determined by the appearance of the external genitalia on ultrasound.

probable signs of pregnance Chadwick Godall signs Hegal Broxton hicks Bellotment

Probable signs of pregnancy Chadwick : Vulva purple Godall signs : Cervix softening Hegal : Uterus softening lower portion

Which individual is least likely to be at risk for the development of Kaposi's sarcoma?

A renal transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environment in which exposure to asbestos is possible answer : 4

Azathioprine is --

Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are reported immediately to the PHCP. The client should also call the PHCP if more than one dose is missed. The medication may be taken with meals to minimize nausea.

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply.

Bread and butter 2. Carrots and peas 3. Peppers and onions 4. Beef and potato salad 5. Avocados and mushrooms answers: 1.2.3

In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.

Change breast pads frequently. 2. Breastfeed infant every 4 hours. 3. Wear an underwire bra for support. 4. Avoid the use of soap on your nipples. 5. Intermittently expose your nipples to the air. 1,4,5

DKA

Client education after DKA should emphasize the need for home glucose monitoring ---four to five times per day. ---It is also important to instruct the client to notify the PHCP when illness occurs. ---The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed.

breast engorgement include ( comfort measures )

Comfort measures for breast engorgement include 1. massaging the breasts before feeding to stimulate let-down, 2. wearing a supportive and well-fitting bra at all times, 3. taking a warm shower or applying warm compresses just before feeding, 4. and alternating breasts during feeding.

Cyclosporine

Cyclosporine is an 1. immunosuppressant medication., the 1-1-1 . client should NOT receive any vaccinations without first consulting the PHCP. 2. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. 3. The client must be able to self-monitor blood pressure to check for the side effect of hypertension

Fundal height second, third trimester

During the second and third trimesters (18-30 weeks' gestation), - the fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 cm. -In addition, at this point in the pregnancy, in a 4 week period, the fundal height should increase approximately 4 cm.

Immunization schedule 12 to 18 month

His ( Hiv) 12 -18 Dispatched ( DTAP) Mumps ( MMR) Vaccines ( Varicella ) Helped ( *HepA*) People ( PVC )

Involution

Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately 1 fingerbreadth or 1 cm per day. The other options do not accurately describe involution.

The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement?

One half the distance between the antecubital fossa and the shoulder 2. One third the distance between the antecubital fossa and the shoulder 3. Two thirds the distance between the antecubital fossa and the shoulder 4. One quarter the distance between the antecubital fossa and the shoulder ans: 3

immunization schedule ( 4-6 years )

Police ( Polio ) Dispatched ( Dtap) 4-6 year old Mump ( MMR) Vacccines ( Varicella )

GTAPAL

Pregnancy outcomes can be described with the GTPAL acronym: -G = gravidity (number of pregnancies); -T = term births (number born after 37 weeks); -P = preterm births (number born before 37 weeks' gestation); -A = abortions/miscarriages (number of abortions/miscarriages); - L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.

HIgh in k+

Rationale: Foods that are high in potassium include 1. bananas, 2. cantaloupe, 3. kiwifruit, 4. oranges, and 5. dried fruits such as raisins. Fruits low in potassium include 1. apples, 2. cherries, 3. grapefruit, 4. canned peaches, 5. pineapple, and 6. cranberries.

1. preoperational stage, 2. sensorimotor stage, 3. concrete operations 4. formal operations stage

1. In the *preoperational stage*, the child is demonstrating *egocentric thinking* by believing the moon's actions revolve around the child. 2. In the *sensorimotor stage*, a child does not believe an *object exists* if it is not in sight. 3. A child in the *concrete operations* stage is able to *classify, order*, and sort facts, such as the multiplication tables. 4. A child in the *formal operations* stage is able to solve more complex problems, such as using a *map* to determine location and directions.

Latax allergy

1. Individuals who are allergic to *kiwis*, *bananas*, *pineapples*, *tropical fruits*, *grapes*, *avocados*, *potatoes*, hazelnuts, and water chestnuts are at risk for developing a latex allergy. 2. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.

Fluid intake

3000ml/day

Jaundice observed in dark skin

1. Petechiae in a dark-skinned client, petechiae are best observed in the conjunctivae and *oral mucosa*. 2. Cyanosis is best noted on the *palms* of the hands and soles of the feet. In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms and soles . In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge 3. Jaundice would best be noted in the *sclera of the eye*.

immunization schedule

1. TWO Six month old Pediatric ( PVC) Policies ( Polio) Discussed ( DTAP ) Rejecting ( RV ) His ( Hiv) Hep B at ( Hep B ) -->4 month ( Except Hep b, all vaccines at 2,6 months )