Health Promo Exam 1 (practice)

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors include cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply) A. Help the client see the benefits of her actions B. Identify the client's support system C. Suggest and recommend community resources D. Devise and set goals for the client E. Teach stress management strategies

A, B, C, E

A client who is NPO, comatose, and receiving oxygen has cracked lips, dry mucus membranes, swollen gums, and caked mucus on the tongue and teeth. What is the best intervention by the nurse? A. Swab the oral cavity with a water-soaked sponge as needed. B. Clean the mouth every half-hour with lemon-glycerin swabs. C. Clean the oral cavity with hydrogen peroxide, followed with water. D. Swab the lips and mucus membranes with mineral oil.

A. Swab the oral cavity with a water-soaked sponge as needed. Rationale: The best intervention is to swab the oral cavity with a water-soaked sponge swab as needed. Swabbing every half-hour with lemon-glycerin swabs leads to further dryness of mucosa and changes in tooth enamel. Aspiration of mineral oil can initiate lipid pneumonia. Swabbing the oral cavity with hydrogen peroxide, followed with water, irritates healthy oral mucosa and may alter the microflora of the mouth.

A nurse in a clinic is caring for a 21 y/o who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

A. Testicular examination

A nurse who provides care on the palliative unit of a hospital is aware of the importance of spiritual assessment and the integration of spirituality into clients' care. What assessment question should the nurse use in an effort to determine clients' spiritual beliefs? a. "Are there any spiritual or religious beliefs or practices that are important to you?" b. "What church do you normally attend?" c. "If you had to identify yourself as either a religious person or a spiritual person, which would you choose?" d. "Do you hold a belief in the afterlife?"

Answer: a. "Are there any spiritual or religious beliefs or practices that are important to you?" Rationale: An open-ended yet clear question about a person's spiritual beliefs is most likely to elicit information about the client in a thoughtful manner. Asking the client to choose between self-identifying as religious or spiritual is not an accurate dichotomy, while asking about the afterlife is not a direct way of assessing religion and spirituality. Not every religious or spiritual group situates their practices in a church.

Which of the following client statements most clearly suggest the potential of a nursing diagnosis of Spiritual Anxiety? a. "Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." b. "I've never been a religious man, and all these Catholic crosses and pictures in the hospital make me a bit uncomfortable." c. "I guess I should have taken a lot more time to go to church when I was younger." d. "I always tried to do the right thing, so I don't understand why I have to suffer so much now.

Answer: a. "Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." Rationale: Worry about one's spiritual condition is indicative of the nursing diagnosis of Spiritual Anxiety. Unfamiliarity with the religious character of a care setting suggest Spiritual Alienation, while questions of suffering often indicate Spiritual Pain or Spiritual Despair. Regrets over previous religious or spiritual apathy may suggest a nursing diagnosis of Spiritual Guilt.

The son of a dying female client is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation? a. Contact the chaplain to arrange a visit with the client. b. Organize a meeting between the chaplain, the son, and the client to achieve a resolution. c. Document the client's request and wait to see if she reiterates her request. d. Perform a detailed spiritual assessment of the client.

Answer: a. Contact the chaplain to arrange a visit with the client. Rationale: The nurse's primary duty is to honor the client's request for a meeting with a spiritual advisor.

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should do what? a. Take measure to ensure privacy during the counselor's visit. b. Ask the spiritual counselor to summarize the visit in the client's medical record. c. Ensure that the counselor is approved by the hospital administration. d. Ask to be present during the visit in order to explain any medical information or answer questions about the client's care.

Answer: a. Take measure to ensure privacy during the counselor's visit. Rationale: Visits between a client and a spiritual counselor require privacy. The details of the meeting are not typically documented in the client's chart, though the fact that the visit took place is often noted. The nurse may be present during the meeting, but this should take place at the client's request. Spiritual counselors do not require administrative approval; clients and their families are normally able to seek spiritual help from whomever they prefer.

A nurse is caring for a terminally ill client who believes that death and reincarnation are the ultimate gifts from God to mankind. Which of the following would be most appropriate to integrate into this client's plan of care when providing spiritual support? a. Subtly attempt to change the client's belief. b. Provide support that builds on the client's faith. c. Provide literature to the client that says otherwise. d. Request the client refrain from talking about death.

Answer: b. Provide support that builds on the client's faith. Rationale: The nurse should support and build on the client's faith. Nurses should not attempt to change faith that clients already posses. If faith is lost, clients will lose hope; without the will to live, many people are beyond the help of the most potent medical powers. The nurse should not attempt to change the client's belief or provide literature that says otherwise. Conversations regarding faith, however, must not pass judgment or present controversy. Clients need to feel accepted in their beliefs and encouraged to remain open in expressing and learning.

While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion? a. Judaism b. Christianity c. Islam d. Hinduism

Answer: c. Islam Rationale: According to the Islamic religion, neither food nor drink is taken between sunrise and sunset during the holy days of Ramadan. There are no special or universal food beliefs common to Christianity. According to Judaism, Kosher food is eaten, meat cannot be mixed with dairy, and separate cooking and eating utensils are used for food preparation and consumption. According to Hinduism, pork and alcohol are forbidden and other meats must meet ritual requirements.

While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements? a. Religion and spirituality are synonymous. b. Spirituality is the behavioral manifestation of religious beliefs. c. Religion is a collection of spiritual beliefs and practices. d. Spirituality is a recently developed alternative to traditional religious belief.

Answer: c. Religion is a collection of spiritual beliefs and practices. Rationale: Spirituality may or may not inlace religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable, and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion; nor is it a recent development.

The nurse is caring for a critically ill client, who informs the nurse that there is conflict between her spiritual beliefs and a proposed health option. What is the nurse's role in this situation? a. The nurse has little role in this situation because it is best managed by the physician. b. The nurse should provide examples of ways other clients from various religions handled the situation. c. Provide a subjective opinion on the appropriate course of action. d. Assist the client in obtaining information to make an informed decision.

Answer: d. Assist the client in obtaining information to make an informed decision. Rationale: The nurse's role in resolving conflicts between spiritual beliefs and treatments is to assist the client in obtaining the information needed to make an informed decision, and to support the client's decision making.

Which of the following food groups would be appropriate to suggest to a client who practices tenets of the Islamic faith? a. Barbecued pork sandwich with a milkshake b. Sliced ham and cheese sandwich and 2% milk c. Salad with crumbled bacon and cheese, with a cup of tea d. Broiled chicken sandwich with skimmed milk

Answer: d. Broiled chicken sandwich with skimmed milk Rationale: Members of the Islamic faith are forbidden to eat pork or drink alcohol.

The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. The nurse who is providing care for the client should recognize that the family is likely which religion? a. Jewish b. Jehovah's Witness c. Christian Scientist d. Roman Catholic

Answer: d. Roman Catholic Rationale: Among the sacraments of the Roman Catholic Church is the anointing of the sick. This specific rite is not a component of Jehovah's Witness, Christian Scientist, or Jewish religious belief.

An older adult who identifies herself as a devout Catholic has recently relocated to an assisted-living facility. The client is please with most aspects of the living situation but laments the fact that the church is not nearby, so attending daily mass is not an option. She is quite upset by this restriction and states, "Going to daily mass was my life." The nurse recognizes that this client is suffering which of the following? a. Spiritual pain b. Hopelessness c. Depression d. Spiritual distress

Answer: d. Spiritual distress Rationale: A diagnosis of depression does not apply to this situation. Spiritual distress involves the inability to integrate meaning and purpose in life, while spiritual pain involves angst over the nature and actions of a higher power. The woman's statements do not directly reflect an outlook of hopelessness.

Upon assessment, the client reports he does not belong to an organized religion. The nurse is correct to interpret this statement as which of the following? a. The client will experience conflicts between religious beliefs and health care options. b. The client's spiritual needs are met. c. The client will not request to see the hospital chaplain or seek spiritual counseling. d. The client is not affiliated with a specific system of belief regarding a higher power.

Answer: d. The client is not affiliated with a specific system of belief regarding a higher power. Rationale: The nurse should not interpret the fact that a client does not belong to an organized religion to mean that the client has no spiritual need; a person may be highly spiritual yet not profess a religion. The client may seek spiritual counseling during hospitalization related to spiritual needs.

When planning care for a client who needs an exercise program, the nurse teaches the client that isotonic exercises, such as walking, are intended to achieve which of the following? (Select all that apply.) A. Increased BP B. Increased muscle tone and improved circulation C. Maintain joint range of motion D. Increase muscle mass and strength E. Decrease heart rate and cardiac output

B, C, D Rationale: Isotonic exercise increases muscle tone, mass, and strength and maintains joint flexibility and circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body. Little or no change in blood pressure occurs.

Which statements by the nurse will be important to include during a presentation on oral health at an intergenerational community center? (Select all that apply.) A. "Schedule a visit to the dentist when your child is ready to attend school." B. "Using a bottle during naps and at bedtime can cause dental caries in a toddler." C. "Most elders have dentures and don't need to worry about oral care." D. "Elders are at risk for periodontal disease." E. "It is important for parents to supervise a child's brushing of his/her teeth."

B, D, E Rationale: If the bottle is given during naps or bedtime, the solution has continuous contact with the toddler's teeth. The child should be seen by a dentist well before starting school; the first visit to the dentist should be when the child is 2 or 3 years old. Parents should supervise children's teeth brushing. Over 50% of older adults have their own teeth. Elders, with or without dentures, need good oral care as their mucous membranes tend to dry with age, placing them at increased risk for periodontal disease.

The client is ambulating for the first time postoperatively and tells the nurse, "I feel faint." Which is the best action by the nurse? A. Tell the client to take rapid, shallow breaths. B. Assist the client to a nearby chair C. Find another nurse to help D. Return the client to the room

B. Assist the client to a nearby chair Rationale: Placing the client in a safe position is the best maneuver. Leaving the client to find help creates an unsafe condition. The client could faint before the nurse can get the client back to the room. Rapid, shallow respirations may increase dizziness.

The nurse is participating in a health promotion fair. When discussing exercise, the nurse should include which point? A. Exercise should be done a minimum of 4 days per week. B. Fast walking is a good form of aerobic exercise. C. Each exercise session should last for at least 45 minutes, and preferably 60. D. If one cannot talk when exercising, then the appropriate level of energy is being used.

B. Fast walking is a good form of aerobic exercise. Rationale: Fast walking is a good form of aerobic exercise. Exercise should occur for a minimum of 30 minutes at least 5 days per week in order to be effective. If one cannot speak when exercising, the exercise is too strenuous and should be decreased in speed or in duration.

A nurse is talking with a client who recently attended a cholesterol screening event and a heart healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking meds to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehab program. Which of the following activities for the client is an example of primary prevention? A. Cholesterol screening B. Nutrition presentation C. Medication therapy D. Cardiac rehabilitation

B. Nutrition presentation

While assessing an older client, the nurse notices that the client's teeth have obvious caries and that the client has difficulty swallowing. The client tells the nurse that the mouth feels very dry. The nurse's primary concern is that the client could experience which of the following health problems from these findings? A. Infection B. Nutritional deficit C. Acute pain D. Altered elimination

B. Nutritional deficit Rationale: The condition of the client's teeth, possible difficulty with chewing comfortably, and dry mouth because of decreased production of saliva may cause a nutritional deficit because the client will tend to eat foods that are easy to swallow rather than nutritious. The other options are also potential problems but, given the assessments, nutrition is the greatest concern at this time.

A nurse is caring for a 20 y/o client who is sexually active and has come to the clinic for a first-time check up. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? A. Measure vital signs B. Encourage HIV screening C. Determine risk factors D. Instruct the client to use condoms

C. Determine risk factors

The client is unresponsive and requires total care. Before performing oral care, what should the nurse assess this client for? A. Presence of pain B. Range of motion C. Gag Reflex D. Condition of the skin

C. Gag Reflex Rationale: The absence of a gag reflex tells the nurse that the client has no defense against aspiration. The other options are more appropriate assessments for bathing the client.

Consists of a biological parent with children, and a new spouse who may or may not have children a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

i. Stepfamily

Firm, yet flexible; Family members are supported and nurtured, but also allowed a certain degree of autonomy a. Clear boundaries b. Rigid boundaries c. Diffuse boundaries

a. Clear boundaries

A family structure of two parents and their offspring; Consists of a husband, wife, and their shared biological children a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

a. Nuclear family

The relatives of nuclear families, such as grandparents or aunts and uncles a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

b. Extended family

As a client comes into the admitting​ area, a nurse notices a jeweled cross on the client​'s necklace. The nurse​ comments, "Great ​look; I can see your religious beliefs are important to ​you," and starts with the spiritual assessment of the client. How would this approach be​ evaluated? a. Complimenting the client​'s appearance is helpful b. No time was taken to establish rapport with the client c. A focus on jewelry might appear materialistic d. It is efficient and effective to dive right into the interview

b. No time was taken to establish rapport with the client Rationale Starting with the spiritual assessment of the client leaves no time to establish rapport with the client. It is not about​ jewelry, compliments, or starting quickly.

Family members are isolated from one another and there is little room for negotiation and individual development a. Clear boundaries b. Rigid boundaries c. Diffuse boundaries

b. Rigid boundaries

A young client has just learned of a diagnosis of stage 4 lung cancer. The client was about to graduate from school and get married. "I can​'t believe in God ​anymore" the client tells the oncology nurse. "He should be ​all-loving." Which situation would the nurse identify the client as​ expressing? a. Spiritual pain b. Spiritual distress c. Depression d. Premarital anxiety

b. Spiritual distress Rationale The client is expressing spiritual distress about the loss of hope in his belief system.

Everyone is in everyone else's business; there is little distinction between family members and there is too much negotiation, resulting in a loss of autonomy a. Clear boundaries b. Rigid boundaries c. Diffuse boundaries

c. Diffuse boundaries

Specific form of an extended family in which 2 nuclear families of unmarried kin live in close proximity to one another; Shares social-support networks, chores, goods, and services a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

c. Extended-kin network family

Both partners are employed either by choice or necessity a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

d. Two-career family

Children who can no longer live with their birth parents may require placement with a family that has agreed to include them temporarily a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

g. Foster family

Family structure that results from teenage births a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

f. Adolescent family

Post-divorce family in which the biological children are now a part of 2 nuclear families (that of the mother and that of the father) a. Nuclear family b. Extended family c. Extended-kin network family d. Two-career family e. Single-parent family f. Adolescent family g. Foster family h. Childless family i. Stepfamily j. Binuclear

j. Binuclear