Health Promotion and Maintenance (#1)

When teaching a caregiver of a 17-month-old about toilet training, which instruction would initially be most appropriate? You Selected: Be sure the toddler is ready before starting to toilet train. Correct response: Be sure the toddler is ready before starting to toilet train. Explanation: All of the instructions are appropriate, but knowing whether the toddler is ready to toilet train is initially most appropriate. Many 17-month-olds do not have the neuromuscular control to be able to be trained. Waiting a few more months until the toddler is closer to age 2 years allows the toddler to develop more control. The caregiver should be taught the signs of readiness for toilet training. Add a Note Question 2 See full question 59s The parent asks the nurse about a 9-year-old child's apparent need for between-meal snacks, especially after school. What information should the nurse include in the teaching plan? You Selected: The child should help with preparing the snacks. Correct response: The child should help with preparing the snacks. Explanation: Snacks are necessary for school-age children because of their high energy level. School-age children are in a stage of cognitive development in which they can learn to categorize or classify and can also learn cause and effect. By preparing their own snacks, children can learn the basics of nutrition (such as what carbohydrates are and what happens when they are eaten). The mother and child should make the decision about appropriate foods together. School-age children learn to make decisions based on information, not instinct. Some knowledge of nutrition is needed to make appropriate choices. Add a Note Question 3 See full question 1m 16s A neonate born by cesarean at 42 weeks' gestation, weighing 4.1 kg (9 lb), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. What is the priority problem for this neonate? You Selected: hypoglycemia Correct response: hypoglycemia Explanation: Increased respiratory rate and tremors are indicative of hypoglycemia, which commonly affects the postterm neonate because of depleted glycogen stores. There is no indication that the neonate has ineffective airway clearance, which would be evidenced by excessive amounts of mucus or visualization of meconium on the vocal cords. Lethargy, not tremors, would suggest infection or hyperthermia. Furthermore, the postterm neonate typically has difficulty maintaining temperature, resulting in hypothermia, not hyperthermia. Decreased cardiac output is not indicated, particularly because the neonate was born by cesarean section, which is not considered a difficult birth. Add a Note Question 4 See full question 3m 36s For an 8-month-old infant, which toy promotes cognitive development? You Selected: Jack-in-the-box Correct response: Jack-in-the-box Explanation: According to Piaget's theory of cognitive development, an 8-month-old child will look for an object once it disappears from sight to develop the cognitive skill of object permanence. Therefore, a jack-in-the-box would promote cognitive development. Activity quilts are appropriate for younger infants, allowing for a familiar area to play. A climbing gym is appropriate for toddlers, but dangerous at this age. Anything strung across a crib, such as a play gym, is a safety hazard — especially to a child who may use it to pull up to a standing position. Add a Note Question 5 See full question 2m 2s A nurse is teaching a pregnant client how to distinguish false labor contractions from true labor contractions. Which statement by the client indicates an understanding of this concept? You Selected: "False labor contractions are usually felt in the abdomen." Correct response: "False labor contractions are usually felt in the abdomen." Explanation: False labor contractions are usually felt in the abdomen. In contrast, true labor contractions are regular, start in the back and radiate to the abdomen, and become more intense during walking.

LvL

A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother? You Selected: "Birth weight doubles by 6 months of age." Correct response: "Birth weight doubles by 6 months of age." Explanation: A general growth parameter is that the birth weight doubles in 6 months and triples in a year. Telling the mother that the baby will eat what he needs is not appropriate. The nurse needs to investigate whether the baby's weight is within the normal parameters of infant weight gain. A bottle-fed baby should not be forced to complete the bottle because this may contribute to obesity. Add a Note Question 2 See full question 1m 49s A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, what should the nurse tell the client? You Selected: Some melanomas have a familial component and she should seek medical advice. Correct response: Some melanomas have a familial component and she should seek medical advice. Explanation: Malignant melanoma may have a familial basis, especially in families with dysplastic nevi syndrome. First-degree relatives should be monitored closely. Malignant melanoma occurs most often in the 20- to 45-year-old age-group. Severe sunburn as a child does increase the risk; however, this client is at increased risk because of her family history. Add a Note Question 3 See full question 1m 38s The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective? You Selected: "My menstrual flow should resume in approximately 6 to 10 weeks." Correct response: "My menstrual flow should resume in approximately 6 to 10 weeks." Explanation: For clients who are bottle-feeding, menstrual flow usually returns in 6 to 10 weeks. Heart palpitations for several weeks are not normal and require further investigation. Reddish lochia at 6 weeks postpartum is not normal and warrants further evaluation. Although varicosities may fade, they rarely disappear completely after childbirth. Add a Note Question 4 See full question 41s The correct procedure for auscultating the client's abdomen for bowel sounds is to: You Selected: listen for 5 minutes in all four quadrants to confirm absence of bowel sounds. Correct response: listen for 5 minutes in all four quadrants to confirm absence of bowel sounds. Explanation: Because of the irregularity of bowel sounds, the nurse should listen for 5 minutes in each quadrant to confirm the absence of bowel sounds. Auscultation is performed before palpation because palpation may affect peristaltic activity. Coughing does not stimulate peristalsis. The client should be positioned supine to provide adequate access to the abdomen. Add a Note Question 5 See full question 1m 22s A client is admitted to the preoperative clinic for a breast biopsy. Which information would the nurse enter into the medical record as objective data? You Selected: Blood pressure 130/90 mm Hg; pulse 100 bpm; respirations 14 breaths/min Correct response: Blood pressure 130/90 mm Hg; pulse 100 bpm; respirations 14 breaths/min Explanation: Objective data is information that the nurse observes or collects by observation. The other options fall into the subjective data category of information. A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? You Selected: "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." Correct response: "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." Explanation: The nurse should instruct the client to use the call button when she needs to use the bathroom. The nurse will need to disconnect the fetal monitor and mark the strip to indicate the activity. If the client's partner disconnects and reconnects the monitor, the nurse can't determine if the readings are accurate. Inserting a catheter without a physician's order or not allowing the client to get out of bed isn't acceptable nursing practice. Add a Note Question 2 See full question 1m 18s A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure? You Selected: Washing the hands and wearing latex gloves Correct response: Washing the hands and wearing latex gloves Explanation: During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand washing alone would neither provide adequate protection nor comply with standard or routine precautions. The nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur during a postpartum assessment. Add a Note Question 3 See full question 5m 23s The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket? You Selected: The client is at risk for injury from fighting the restraints. Correct response: The client is at risk for injury from fighting the restraints. Explanation: A full-length restraint blanket is added when the client is at risk for injury from fighting the restraints. The increased degree of restriction is justified only when the risk of client injury increases. Feeling more secure is not a sufficient cause for using a more restrictive measure. Client statements that restraints are tight and uncomfortable require the nurse to assess the situation and adjust the restraints if necessary to ensure adequate circulation. Four-way restraints already provide adequate protection for the staff. Add a Note Question 4 See full question 3m The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first? You Selected: Call the rapid response team (RRT)/medical emergency team. Correct response: Call the rapid response team (RRT)/medical emergency team. Explanation: The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first. Add a Note Question 5 See full question 1m 55s A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should wear gloves when: You Selected: providing mouth care. Correct response: providing mouth care. Explanation: Standard precautions stipulate that a health care worker wear gloves when contact with a client's blood or body fluids is anticipated, such as when providing mouth care. Such barrier protection helps prevent viruses from entering the bloodstream. Maintaining strict isolation isn't needed because human immunodeficiency virus (HIV) is spread by contact with contaminated blood or body fluids, which can be avoided by following standard precautions. A private room wouldn't provide barrier protection, which is needed for standard precautions. Providing routine blood pressure, entering the room, or delivering the food tray is not necessary unless anticipating splashing of blood or body fluids. According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? You Selected: industry versus inferiority Correct response: industry versus inferiority Explanation: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence. Add a Note Question 2 See full question 1m 15s A client has her first prenatal visit at 15 weeks' gestation. Which finding requires further investigation? You Selected: Fundal height of 18 cm Correct response: Fundal height of 18 cm Explanation: Fundal height (in centimeters) should equal the number of weeks' gestation. This client should have a fundal height of 15 to 16 cm. The blood pressure, urine, and weight findings are within normal limits for this client. Add a Note Question 3 See full question 36s Which factor places a client at greatest risk for skin cancer? You Selected: fair skin and history of chronic sun exposure Correct response: fair skin and history of chronic sun exposure Explanation: Caucasians who have fair skin and a high exposure to ultraviolet light are at increased risk for malignant neoplasms of the skin. The other risk factors include exposure to tar and arsenicals and family history. History of hypertension is a coronary artery disease risk factor. Clients with dark skin have increased melanin and are not as prone to skin cancer. Add a Note Question 4 See full question 4m 7s Which factors influence safe and effective medication administration for elderly clients? You Selected: There is less efficient absorption, detoxification, and elimination. Correct response: There is less efficient absorption, detoxification, and elimination. Explanation: When giving medications to elderly individuals, consideration needs to be made for physiologic changes associated with aging. There may be poor absorption from the intestines as well as inadequate elimination. In addition, the liver may be inefficient in detoxification. For the elderly, there is an increased risk of drug interactions because of the number of medications prescribed. They could forget to take the meds. There is less likelihood of solubility and distribution. Add a Note Question 5 See full question 3m 33s After teaching a community class to new parents, the nurse evaluates client understanding of strategies to prevent sudden infant death syndrome (SIDS). Which statements indicates appropriate understanding? You Selected: "I will place my baby in a supine position for sleep during the first year." Correct response: "I will place my baby in a supine position for sleep during the first year." Explanation: SIDS has no specific cause but occurs most often in male infants who were low birth weight, were placed on their stomachs for sleep, and had mothers who used tobacco or alcohol. Caucasian infants have a lower risk than children of color. SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2-4 months. The nurse is assessing a client with hepatitis A and notices that the aspartate transaminase (AST) and alanine transaminase (ALT) lab values have increased. Which statement by the client indicates the need for further instruction by the nurse? You Selected: "I take acetaminophen for arthritis pain." Correct response: "I take acetaminophen for arthritis pain." Explanation: Acetaminophen is toxic to the liver and should be avoided in a client with liver dysfunction. Increased periods of rest allow for liver regeneration. A low-fat, high-carbohydrate diet and dry toast to relieve nausea are appropriate. Add a Note Question 2 See full question 51s The mother of a 9-month-old infant asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. What should the nurse instruct the mother to do? You Selected: Offer new foods one at a time. Correct response: Offer new foods one at a time. Explanation: Infants should be offered new foods one at a time. This gives the infant the chance to become gradually familiar with a variety of food tastes and textures and also helps identify any allergies or adverse reactions to a specific food. Mixing new foods with formula, breast milk, or other familiar foods would make it impossible to satisfactorily detect allergic or other unfavorable reactions. This practice may also cause the infant to refuse familiar foods. If a new food is offered after the infant's appetite is satisfied with formula or breast milk, the infant is not likely to eat the new food. Add a Note Question 3 See full question 2m 29s A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, the nurse should suggest that the client ask the physician about which topic? You Selected: Genetic counseling Correct response: Genetic counseling Explanation: The nurse should suggest that the client ask the physician about genetic counseling. Genetic counseling is indicated for those at high risk because of family or personal cancer history. Genetic counseling involves obtaining a detailed medical and three-generational family history; calculating a personalized risk assessment; providing options for prevention, surveillance, and genetic testing; coordinating and interpreting genetic testing; and developing a management plan based on the test results. Mammography will assist with early detection of most breast cancers, but it won't establish a risk assessment and provide options for prevention, surveillance, and genetic testing. Pap testing every 6 months assists in early detection of most cervical cancers, but it won't establish a risk assessment. Contacting the American Cancer Society (Canadian Cancer Society) won't help assess the client's risk for developing cancer. Add a Note Question 4 See full question 3m 6s The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what should the nurse do first? You Selected: Prepare a clean area on which to receive the neonate. Correct response: Prepare a clean area on which to receive the neonate. Explanation: Because the birth is imminent and no additional help is available, the nurse should immediately prepare a clean area for childbirth. Most agency labor units have emergency birth packs with sterile towels, a bulb syringe, and a cord clamp. Having the client push with a contraction may push the head out quickly, resulting in tearing of the perineum. The nurse should instruct the client to pant or pant/blow to decrease the urge to push. Trying to delay the birth is contraindicated. The head of the bed should be elevated to about 45 degrees, not lowered. The client should assume a position of comfort. Add a Note Question 5 See full question 3m 6s A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. You Selected: The neonate displays weak, ineffective sucking. The neonate doesn't respond when the nurse claps her hands above him. Correct response: The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate displays weak, ineffective sucking. Explanation: Perinatal asphyxia is an insult to the fetus or newborn due to the lack of oxygen. If the neonate's toes do not curl downward when the soles of the feet are touched and the neonate does not respond to a loud sound, neurologic damage from asphyxia may have occurred. A normal neurologic response would be the downward curling of the toes when touched and extension of the arms and legs in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate would grasp a person's finger when it is placed in the palm of the neonate's hand, do stepping movements when held upright with the sole of the foot touching a surface, and turn toward the nurse's finger when touching the cheek.The nurse is assessing a client with hepatitis A and notices that the aspartate transaminase (AST) and alanine transaminase (ALT) lab values have increased. Which statement by the client indicates the need for further instruction by the nurse? You Selected: "I take acetaminophen for arthritis pain." Correct response: "I take acetaminophen for arthritis pain." Explanation: Acetaminophen is toxic to the liver and should be avoided in a client with liver dysfunction. Increased periods of rest allow for liver regeneration. A low-fat, high-carbohydrate diet and dry toast to relieve nausea are appropriate. Add a Note Question 2 See full question 51s The mother of a 9-month-old infant asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. What should the nurse instruct the mother to do? You Selected: Offer new foods one at a time. Correct response: Offer new foods one at a time. Explanation: Infants should be offered new foods one at a time. This gives the infant the chance to become gradually familiar with a variety of food tastes and textures and also helps identify any allergies or adverse reactions to a specific food. Mixing new foods with formula, breast milk, or other familiar foods would make it impossible to satisfactorily detect allergic or other unfavorable reactions. This practice may also cause the infant to refuse familiar foods. If a new food is offered after the infant's appetite is satisfied with formula or breast milk, the infant is not likely to eat the new food. Add a Note Question 3 See full question 2m 29s A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, the nurse should suggest that the client ask the physician about which topic? You Selected: Genetic counseling Correct response: Genetic counseling Explanation: The nurse should suggest that the client ask the physician about genetic counseling. Genetic counseling is indicated for those at high risk because of family or personal cancer history. Genetic counseling involves obtaining a detailed medical and three-generational family history; calculating a personalized risk assessment; providing options for prevention, surveillance, and genetic testing; coordinating and interpreting genetic testing; and developing a management plan based on the test results. Mammography will assist with early detection of most breast cancers, but it won't establish a risk assessment and provide options for prevention, surveillance, and genetic testing. Pap testing every 6 months assists in early detection of most cervical cancers, but it won't establish a risk assessment. Contacting the American Cancer Society (Canadian Cancer Society) won't help assess the client's risk for developing cancer. Add a Note Question 4 See full question 3m 6s The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what should the nurse do first? You Selected: Prepare a clean area on which to receive the neonate. Correct response: Prepare a clean area on which to receive the neonate. Explanation: Because the birth is imminent and no additional help is available, the nurse should immediately prepare a clean area for childbirth. Most agency labor units have emergency birth packs with sterile towels, a bulb syringe, and a cord clamp. Having the client push with a contraction may push the head out quickly, resulting in tearing of the perineum. The nurse should instruct the client to pant or pant/blow to decrease the urge to push. Trying to delay the birth is contraindicated. The head of the bed should be elevated to about 45 degrees, not lowered. The client should assume a position of comfort. Add a Note Question 5 See full question 3m 6s A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. You Selected: The neonate displays weak, ineffective sucking. The neonate doesn't respond when the nurse claps her hands above him. Correct response: The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate displays weak, ineffective sucking. Explanation: Perinatal asphyxia is an insult to the fetus or newborn due to the lack of oxygen. If the neonate's toes do not curl downward when the soles of the feet are touched and the neonate does not respond to a loud sound, neurologic damage from asphyxia may have occurred. A normal neurologic response would be the downward curling of the toes when touched and extension of the arms and legs in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate would grasp a person's finger when it is placed in the palm of the neonate's hand, do stepping movements when held upright with the sole of the foot touching a surface, and turn toward the nurse's finger when touching the cheek. Encouraging fantasy play and participation by children in their own care is a useful developmental approach for which pediatric age-group? You Selected: Preschool age (3 to 5 years) Correct response: Preschool age (3 to 5 years) Explanation: Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation. Allow choices when possible. Add a Note Question 2 See full question 57s The nurse must be aware that adverse drug reactions in the elderly client may be underestimated because: You Selected: physical or psychological symptoms are attributed to the effects of aging. Correct response: physical or psychological symptoms are attributed to the effects of aging. Explanation: The elderly client commonly has vague or atypical responses to medications and diseases that are erroneously attributed to aging. A new cognitive change needs to be investigated and is not an expected change with aging. Changes in a client's behavior should be investigated to see whether there is a relation to excessive sedation. The nurse can interview the family members to obtain information. Add a Note Question 3 See full question 22s The fetus of a multigravid client at 38 weeks' gestation is determined to be in a frank breech presentation. The nurse describes this presentation to the client as which fetal part coming in contact with the cervix? You Selected: buttocks Correct response: buttocks Explanation: In a frank breech, the buttocks alone are at the cervix, while the knees are extended to rest on the chest. In a cephalic presentation, the head is the fetal body part first coming in contact with the cervix. Both feet at the cervix is termed double footling breech. In a shoulder presentation, one of the shoulders (actually the acromion process) presents to the cervix. Typically, the fetus is lying horizontally (transverse lie). Add a Note Question 4 See full question 33s It is important for nurses to communicate with clients about their health care because: You Selected: health care services are often specialized and fragmented. Correct response: health care services are often specialized and fragmented. Explanation: Managing clients' health involves many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring. One of the significant roles of the nurse is to ensure clear communication with the client and among the health care team. Due to expanded media coverage of health care issues, clients may be more aware of health care issues, but may not be able to determine if the information is accurate or pertains to them. Because of increasing numbers of media sources, both digital and print, it is difficult for consumers to keep up with all of the advances in the science of health care. Clients are more aware of their rights because of media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well, and communication should not be impacted by a client's knowledge or demand for those rights. Add a Note Question 5 See full question 1m 2s A woman who gave birth to her last infant by caesarean birth is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo "a trial labor." What does the nurse explain to the client that trial of labor means? You Selected: Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Correct response: Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Explanation: A trial labor in this context means that the woman is allowed to go into labor, and her progress is assessed by cervical dilation and effacement as well as fetal descent evaluated to determine whether to allow the labor to progress to delivery. If there are indications that labor is not progressing, other means of delivery are considered. Labor stimulation is used cautiously and may not be safe. The presence of contractions every 5 minutes indicates true labor. If fetal distress is noted and an emergency cesarean birth cannot be done immediately, tocolytic agents may be considered to stop contractions.

LvL 0 to 1

Parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age: You Selected: is highly sensitive to criticism. Correct response: is highly sensitive to criticism. Explanation: A nurse should explain that a 6-year-old child has a precarious sense of self that can cause overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and actually love the routine of a schedule. Tattling is more common at age 4 or 5; by age 6, the child wants to make friends and be a friend. Add a Note Question 2 See full question 42s Urinary tract infection (UTI) is a potential problem after spinal cord injury. To prevent an UTI, the nurse should encourage the client to: You Selected: drink at least 2,000 mL of fluid daily. Correct response: drink at least 2,000 mL of fluid daily. Explanation: As soon as the client's vasomotor status stabilizes and is not susceptible to fluid volume overload, it is essential to drink at least 2,000 mL of fluid daily. Increased fluid intake helps flush out bacteria and prevents urinary stasis. Citrus juices are not encouraged. They can promote a urinary tract infection because they are alkaline-forming. Most citrus fruits are not metabolized as acids in the body. Extra protein does not decrease the potential for a urinary tract infection. While washing hands frequently is an appropriate health habit, UTIs in clients with spinal cord injuries primarily are caused by urinary stasis, and not prevented by handwashing. Add a Note Question 3 See full question 31s Which client should the nurse most encourage to receive the pneumococcal and influenza vaccination? You Selected: a 75-year-old client with diabetes Correct response: a 75-year-old client with diabetes Explanation: Clients who have a chronic illness, have experienced a serious illness, reside in long-term care facilities, or are 65 years of age or older are encouraged to obtain pneumococcal and influenza vaccinations. Having angina or benign prostatic hypertrophy would not predispose a client to pneumonia or influenza. Pregnancy is not a contraindication, but this woman is not at high risk for these diseases. Add a Note Question 4 See full question 39s A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first? You Selected: Complete a vaginal examination. Correct response: Complete a vaginal examination. Explanation: The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by completing a vaginal exam to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining naloxone. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client. Add a Note Question 5 See full question 21s A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program? You Selected: creating a safe environment for sharing information Correct response: creating a safe environment for sharing information Explanation: Creating an environment where the teenagers feel safe to share their information leads to therapeutic communication that is client focused. This helps to establish trust, which facilitates a more successful program. The other options block the ability of the teenagers to share their thoughts and feelings openly.

LvL 2 to 3

A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit? You Selected: Describe each of the potential causes and possible treatment modalities. Correct response: Describe each of the potential causes and possible treatment modalities. Explanation: By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility. Add a Note Question 2 See full question 27s A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child? You Selected: has a strong sense of justice and fair play Correct response: has a strong sense of justice and fair play Explanation: School-age children are concerned about justice and fair play. They become upset when they think someone is not playing fair. Physical affection makes them embarrassed and uncomfortable. They are concerned about others and are cooperative in play and school. Add a Note Question 3 See full question 46s The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which support? You Selected: praise and encouragement Correct response: praise and encouragement Explanation: The adolescent client may have special needs during the postpartum period. Praise and encouragement of her mothering skills are important for building the client's confidence and self-esteem. Although they may be helpful in some instances, detailed written instructions or prolonged verbal instructions are inappropriate. Lengthy explanations, either verbal or in writing, may overwhelm the first-time mother, adding to her fears and feelings of inadequacy. Family availability is important but not essential. For example, it is not essential that the client's mother assist her. However, the nurse can instruct the client while her mother is present. Peer acceptance is a major component of adolescence, but lack of knowledge or experience about infant care is unrelated to peer acceptance. The reality of caring for a neonate may be a crisis for the adolescent. Add a Note Question 4 See full question 3m 33s When assessing a 13-year-old adolescent, what is an expected finding? You Selected: Tanner stage I of development Correct response: subjective judgments of right and wrong Explanation: For the adolescent, moral development occurs as abstract reasoning develops. Moral issues are seen to differ based on opinions. Many adolescents at age 13 have reached at least Tanner stage II, an assessment of the development of secondary sex characteristics. Many adolescents at this age do not have a career choice in mind yet. Typically, adolescents have more than one friend. Add a Note Question 5 See full question 1m 19s The parents of a 3-week-old healthy newborn ask the nurse why their child is intermittently cross-eyed. What is the nurse's best response? You Selected: "It is normal to have eye crossing in the newborn period." Correct response: "It is normal to have eye crossing in the newborn period." Explanation: During the first few months of life, an infant's eyes may wander and appear to be crossing. As the eye muscles mature, between 2 and 3 months of age, both eyes will focus on the same thing. No intervention is necessary, as crossing of the eyes is normal in the first few months of life. A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers use ritualistic patterns to establish which factor? You Selected: a sense of security Correct response: a sense of security Explanation: Toddlers establish ritualistic patterns to feel secure, despite inconsistencies in their environment. Establishing a sense of identity is the developmental task of the adolescent. The toddler's developmental task is to use rituals and routines to help in making autonomy easier to accomplish. Ritualistic patterns do involve patterns of behavior, but they are not utilized to develop learning behaviors. Add a Note Question 2 See full question 29s A 30-year-old client is being treated for epididymitis. What information should the nurse include in the teaching plan about the likely cause of epididymitis? You Selected: sexually transmitted infection Correct response: sexually transmitted infection Explanation: Among men younger than age 35, epididymitis is most frequently caused by a sexually transmitted infection. Causative organisms are usually chlamydia or Neisseria gonorrhoeae. The other major form of epididymitis is bacterial, caused by the Escherichia coli or Pseudomonas organisms. The nurse should always include safe sex teaching for a client with epididymitis. The client should also be advised against anogenital intercourse because this is a mode of transmission of gram-negative rods to the epididymis. Add a Note Question 3 See full question 21s After a person experiences a closure of the epiphyses, which statement is true? You Selected: No further increase in bone length occurs. Correct response: No further increase in bone length occurs. Explanation: After closure of the epiphyses, no further increase in bone length can occur. The other options are inappropriate and not related to closure of the epiphyses. Add a Note Question 4 See full question 49s A client at an outpatient psychiatric clinic has been experiencing anxiety. The nurse would like to suggest activities for the client to do in his/her spare time. What would be an appropriate activity for the nurse to suggest to the client? Select all that apply. You Selected: Stretching exercises Daily walks Taking up a hobby Correct response: Taking up a hobby Daily walks Stretching exercises Explanation: Taking daily walks and stretching exercises allow the client to expend energy and establish a trusting, neutral relationship with the nurse. Taking up a hobby will help the client change their attention and focus from negative anxiety to more positive and relaxed thoughts. The other suggestions are higher stimulation activities that insert competition and added anxiety to the situation. Add a Note Question 5 See full question 23s The nurse is teaching a group of high school students about risk-taking behaviors. Which of the following topics would be considered an example of healthy behaviors? You Selected: Motor vehicle accidents Correct response: Preventative vaccinations Explanation: Preventative vaccinations are not associated with a risk-taking behavior. Vaccinations are used as vehicles to prevent communicable diseases rather than living dangerously. The other choices are all associated with risk-taking behaviors: smoking, drinking, and motor vehicle accidents. These are especially important to discuss with young adults.

LvL 3 to 4

Which child should the nurse assess as demonstrating behaviors that need further evaluation? You Selected: Stephen, age 2, who is indifferent to other children and adults and is mute Correct response: Stephen, age 2, who is indifferent to other children and adults and is mute Explanation: Indifference to other people and mutism may be indicators of autism and would require further investigation. A 2-year-old who talks to himself and refuses to cooperate with toilet training is displaying behaviors typical for this age. Occasional thumb sucking and not having spent the night with a friend would be normal at age 6. Threatening to run away when angry is considered within the range of normal behaviors for a 10-year-old child. Add a Note Question 2 See full question 58s The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to: You Selected: iron deficiency. Correct response: iron deficiency. Explanation: Excessive milk consumption can lead to the displacement of iron-rich foods in the diet. This can result in iron deficiency anemia. Drinking excess milk will not cause vitamin C, biotin, or folate deficiencies. Add a Note Question 3 See full question 3m 50s To meet the developmental needs of an 8-year-old child who is confined to home with osteomyelitis, what goal should the nurse include in the care plan? You Selected: Allow siblings to visit freely throughout the day. Correct response: Encourage the child to communicate with schoolmates. Explanation: Add a Note Question 4 See full question 58s A woman who is breastfeeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" What information should the nurse give the client? You Selected: gradual decrease in milk supply as the baby nurses less Correct response: gradual decrease in milk supply as the baby nurses less Explanation: Over time, as the infant nurses less, the mother's milk supply diminishes normally. Gradual weaning by eliminating one feeding at a time over several weeks is the best recommendation. Lactation suppressants are no longer recommended because of the possible adverse effects, such as hypotension. Mechanical methods of suppressing lactation, such as a breast binder, are most effective when used as soon after childbirth as possible. The milk supply persists beyond 6 months after birth if the breasts are emptied regularly. Add a Note Question 5 See full question 1m 24s The nurse is developing an educational program about prostate cancer. The nurse should provide information about which topic? You Selected: For all men, age 50 and older, the American and Canadian Cancer Societies recommend an annual rectal examination. Correct response: For all men, age 50 and older, the American and Canadian Cancer Societies recommend an annual rectal examination. Explanation: Most cases of prostate cancer are adenocarcinomas. An adenocarcinoma is palpable on rectal examination because it arises from the posterior portion of the gland. Although the PSA is not a perfect screening test, the American Cancer Society and the Canadian Cancer Society recommend an annual rectal examination and blood PSA level for all men age 50 years and older, or starting at age 40 years if the client is of African descent, or if there is family history of prostate cancer. A colonoscopy is performed to diagnose colon cancer, not prostate cancer. Regular sexual activity does not prevent cancer of the prostate. 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? You Selected: Up to 20 Correct response: 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. Add a Note Question 2 See full question 46s A nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? You Selected: One fingerbreadth below the umbilicus Correct response: One fingerbreadth below the umbilicus Explanation: After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis. Add a Note Question 3 See full question 3m 52s The nurse should teach the diabetic client that which is most indicative of hypoglycemia? You Selected: bradycardia Correct response: nervousness Explanation: The four most commonly reported signs and symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Other signs and symptoms include hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul's respirations are clinical manifestations of hyperglycemia or ketoacidosis. Bradycardia is not associated with hypoglycemia; tachycardia is. Add a Note Question 4 See full question 36s Which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in activities of daily living? You Selected: eliminating smoking and alcohol use Correct response: eliminating smoking and alcohol use Explanation: Smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux. They therefore should be avoided by clients with hiatal hernia. Daily aerobic exercise, balancing activity and rest, and avoiding high-stress situations may increase the client's general health and well-being, but they are not directly associated with hiatal hernia. Add a Note Question 5 See full question 5m 7s The nurse is assessing the development of an 18-month-old. The child should be able to: You Selected: throw a ball overhand. Correct response: say three words. Explanation: By age 18 months, 90% of children can say three words. Typically, a child 23 months of age can build a tower of four cubes. The ability to use a spoon or fork with little spilling is accomplished by the age of 20 months. Throwing a ball overhand typically is achieved by age 3.

LvL 4 to 5

A girl has a urinary tract infection (UTI). Which statement by the parent demonstrates understanding of preventing future UTIs? You Selected: "I shouldn't let my daughter take bubble baths." Correct response: "I shouldn't let my daughter take bubble baths." Explanation: Saying that the child should not take bubble baths demonstrates effective teaching 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 are not given prophylactically. No evidence suggests that warm baths help prevent UTIs. Add a Note Question 2 See full question 1m 25s Which toy is appropriate for a 3-year-old child? You Selected: a puzzle with large pieces Correct response: a puzzle with large pieces Explanation: A puzzle is the most appropriate toy because, at age 3, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5- or 6-year-old child; a pull toy, for a toddler; and a computer game, for a school-age child. Add a Note Question 3 See full question 23s A client is brought to the health clinic for a routine checkup. To assess the client's vision, the nurse should ask You Selected: "How are you doing in school?" Correct response: "How are you doing in school?" Explanation: The nurse should ask about school because a client's poor progress in school may indicate a visual disturbance. Asking whether a client has problems with seeing colors, seeing at night, or glare is more appropriate when assessing vision in an elderly client. Add a Note Question 4 See full question 1m 22s A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit? You Selected: Edema Correct response: Edema Explanation: At each prenatal visit, the nurse should assess the client for edema because edema, increased blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic measurements and Rh typing are determined at the first visit only because they don't change. The nurse should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation. Add a Note Question 5 See full question 48s The mother says that the infant's primary care provider recommends certain foods, but the infant refuses to eat them after breastfeeding. How should the nurse suggest that the mother alter the feeding plan? You Selected: Allow the infant to nurse for a few minutes and then offering solid foods. Correct response: Allow the infant to nurse for a few minutes and then offering solid foods. Explanation: It is typical for an infant just starting on solid foods to spit them out because the infant does not know how to swallow them. Also, the infant is hungry and is accustomed to having milk to satisfy that hunger. It is generally recommended that an infant be given some milk first and then offered solid foods. Offering dessert followed by vegetables and meat is inappropriate because the infant will learn to prefer the sweets first and then possibly refuse the vegetables and meats. Offering breast milk as long as the infant refuses solid foods is inappropriate because an infant who fills up on breast milk will have no interest in the solids. Mixing pureed foods with breast milk is inappropriate because solid food should be given with a spoon. Also, using a large-holed nipple may cause the infant to choke from getting too much fluid at one time.

LvL 6 to 7

The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should: You Selected: encourage the client to avoid standing in one position for long periods of time. Correct response: encourage the client to avoid standing in one position for long periods of time. Explanation: The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distended veins, but there is no indication that the client should contact the health care provider at this point in time. The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time. Add a Note Question 2 See full question 1m 18s Which activity would the nurse suggest to a mother to best support her 4-year-old child's developmental needs? You Selected: participation in parallel play Correct response: playing kick ball Explanation: Playing kick ball requires the preschooler to use a variety of motor skills, can help channel energy, and meets developmental needs. Participation in parallel play is more appropriate for a younger child. Although the preschooler can ride a tricycle well, riding a bicycle requires more balance than a 4-year-old child is likely to have. Stringing large beads is appropriate for a younger child. Add a Note Question 3 See full question 24s As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that: You Selected: laryngeal cancer is one of the most preventable types of cancer. Correct response: laryngeal cancer is one of the most preventable types of cancer. Explanation: Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer. Add a Note Question 4 See full question 35s While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which factor? You Selected: decreased blood volume in the vascular system Correct response: decreased blood volume in the vascular system Explanation: The client's dizziness is most likely caused by orthostatic hypotension secondary to the decreased volume of blood in the vascular system resulting from the physiologic changes occurring in the mother after birth. The client is experiencing dizziness because not enough blood volume is available to perfuse the brain. The nurse should first allow the client to "dangle" on the side of the bed for a few minutes before attempting to ambulate. By 6 hours postpartum, the effects of the anesthesia should be worn off completely. Typically, the effects of epidural anesthesia wear off by 1 to 2 hours postpartum, and the effects of local anesthesia usually disappear by 1 hour. The client scenario provides no information to indicate that the client experienced any postpartum hemorrhage. Normal blood loss during birth should not exceed 500 mL. Add a Note Question 5 See full question 1m 58s A young child with a history of bronchial asthma is brought to the emergency department for the second time in a month with symptoms of audible expiratory wheezing and intercostal retractions. The parents voice frustration about repeated hospital visits. What information is most important for the nurse to address with the parents? You Selected: providing a variety of resources to help the parents quit smoking Correct response: providing a variety of resources to help the parents quit smoking Explanation: Smoking is a main allergen that can initiate the inflammatory response in children with bronchial asthma. Few children with bronchial asthma will remain asymptomatic for the remainder of their lives. As many as one in two children who had childhood asthma and who are asymptomatic at 18 years of age are likely to have recurrent, symptomatic disease by age 26 years. Asthma usually persists as a low-grade, subclinical condition. Asthmatic episodes may be life threatening in all age groups.

LvL 7 to 8