Health Promotion and Maintenance

A client is readmitted to the acute care facility. During the admission assessment, the client reports not taking the medication as prescribed. What is the best response by the nurse?

"Please tell me about how you take your medications?"

The client who is receiving chemotherapy is not eating well but otherwise feels healthy. What should the nurse suggest the client eat?

broiled chicken, green beans, and cottage cheese

A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment?

allowing extra time for the assessment

The nurse is teaching a client about preventing toxic shock syndrome (TSS). Which action is a risk factor for toxic shock syndrome?

using only tampons at night

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention?

removing the initial dressing for incision inspection

A nurse teaches an adolescent client with asthma to independently administer breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?

Adolescents are worried about appearing different from their peers.

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant?

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant?

When assessing speech development, the nurse should refer which child for further revaluation?

an 18-month-old who only says "no"

When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method?

back up and out

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?

creating a safe environment for sharing information

The nurse is caring for expectant and new mothers. The nurse would encourage breastfeeding for the client who is:

diagnosed with mastitis.

The nurse conducts a wellness screening on a 9-year-old client Which finding most suggests that that the client has typical social development?

has a best friend

According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage?

industry versus inferiority

An obese diabetic client has bilateral leg aching is to start a cardiac rehabilitation with an exercise program. Using which exercise equipment will be most helpful to the client?

stationary bicycle

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period?

2 to 4 days

The nurse is working with a client with low proficiency in the dominant language. The client's spouse is fluent in both the client's language and the area's dominant language. What is the best action by the nurse when providing discharge education to the client and spouse?

Obtain the services of a medical interpreter.

The nurse is teaching a client about avoidance therapy to improve allergic rhinitis. What should be included in the teaching? Select all that apply.

Use air cleaners. Shower after being outside. Use saline nasal spray.

A client asks the nurse how frequently she should have a mammogram. The nurse assesses that there is no family history of breast cancer and no risk factors with this particular client. Which statement by the client shows an understanding of the nurse's teaching regarding the frequency of mammograms?

"I should have a mammogram at age 50, and then every 2 years until age 74."

The nurse notes that an infant stares at an object placed in her hand and takes it to her mouth, coos and gurgles when talked to, and sustains part of his own weight when held in a standing position. The nurse correctly interprets these findings as characteristic of an infant at which age?

4 months

When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next?

No action is needed; this is a normal finding.

A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?

breast sensitivity

While waiting for the placenta to deliver, the nurse should not take any action before which action has occurred?

observing for signs of placental separation

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?

sexually transmitted infection

Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?

sole creases covering the entire foot

A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be most appropriate?

"Babies can't digest solid food properly until after they are 4 months old."

A parent calls the clinic to report their 9-month-old infant has had 5 soft to loose stools today, has a decreased appetite, but is alert and playing. Which advice is most appropriate for the nurse to give the parent?

"Continue your infant's normal feedings."

During a routine physical examination, a male client informs the nurse that he frequently participates in anal intercourse with his sexual partner. What education is important for the nurse to include with health teaching?

The client should wear a condom during anal intercourse.

While performing an assessment, a nurse observes a 6-month-old infant transferring an object from one hand to another and reaching for the nurse's stethoscope. The parent tells the nurse this is new behavior and asks if it is normal. The nurse educates the parent about growth and development parameters for a 6-month-old infant. What does she tell the parent?

"This behavior is typical for a 6-month-old infant."

A parent asks the nurse about the nutritional needs of her toddler. Which response by the nurse would be most appropriate?

"Toddlers have definite food preferences."

A mother tells the nurse she understands breastfeeding is the best, but will change to formula feedings when she returns to work in a few weeks. What should the nurse tell this mother about formula feedings? Select all that apply.

"When mixing the powdered formula, be sure to follow the manufacturer's directions on the container to ensure proper nutrition." "All babies on formula should have an iron-fortified formula to ensure healthy brain growth." "Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding."

The mother of a neonate expresses concern about how to continue breastfeeding when she returns to work in 6 weeks. How should the nurse respond?

"You can develop and practice a plan now for expressing milk and feeding so you're ready."

The nurse is planning an educational program about the prevention of osteoporosis for a group of women. Which preventive measures would be appropriate for the nurse to include in the teaching plan?

encouraging weight-bearing exercise on a regular basis

A client undergoes intense rehabilitation after a cerebrovascular accident (CVA) and is being discharged with residual hemiparesis. What is the most important responsibility of the case manager?

Assess capabilities, demonstrate the use of assistive devices, and assess how the client will manage at home.

A primigravid client at 16 weeks' gestation visits the clinic for a routine examination. The client tells the nurse that she knows someone whose baby was born with congenital toxoplasmosis. What should the nurse instruct the client to do to prevent transmission of the toxoplasmosis protozoan?

Cook all meats, such as beef and pork, thoroughly.

The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's best action?

Document the findings in the newborn's chart.

The nurse is preparing information for a community health fair. Which information should the nurse include to promote healthy skin?

Drink an adequate amount of water.

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

Explore the client's strengths and resources with her.

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?

Offer new foods one at a time.

An obese adolescent tells the nurse that he would like to lose weight and asks the nurse's opinion on how to accomplish his goal. Which suggestion would be most appropriate?

Participate in an adolescent weight-reduction program.

A child with diabetes insipidus will be receiving injectable vasopressin when discharged from the hospital. What is the most important step when teaching injection techniques?

Teach injection techniques to anyone who will provide care for the child as well as to the child if the child is old enough to understand.

A school health nurse is teaching a group of 7-year-old girls about preventing urinary tract infections. What is the most appropriate education for the nurse to include in the teaching?

Tell the girls to avoid bubble baths and other perfumed bath additives.

While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains about the neonate's need for gavage feeding at this time instead of the mother's plan for bottle feeding. What should the nurse include as the rationale for this feeding plan?

The neonate has difficulty coordinating sucking, swallowing, and breathing.

Parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate?

The quality of food that a preschooler consumes is more important than the quantity.

A parent tells the nurse that the primary discipline method used in the home is corporal punishment. What should the nurse should tell the parent about corporal punishment?

Use can result in children becoming accustomed to spanking.

During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that her breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure?

Use her hand or a pump to express a small amount of breast milk before breastfeeding. SUBMIT ANSWER

A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that fetal movement can be felt beginning at which time?

between 18 and 20 weeks' gestation

Which toy should the nurse give to a toddler to use in the hospital playroom?

blocks

When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly?

blood pressure

A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate?

checking for the umbilical cord around the neonate's neck

The nurse is assessing a client's testes. Which finding indicate the testes are normal?

egg-shaped

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

helps lungs remain expanded after the initiation of breathing improving oxygenation

The nurse determines the parents' compliance with treatment for their infant who has otitis media. Which behavior would indicate that the parents are adhering to the treatment plan?

holding the child upright when feeding with a bottle

After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates which factor?

immaturity of the central nervous system

A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret this finding?

normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation

A child, age 4, is brought to the clinic for a routine examination. When observing the tympanic membrane, the nurse identifies which color as normal?

pinkish gray

A mother tells the nurse that her 4 1/2-year-old child "does not seem to know the difference between right and wrong." This behavior is typical of which levels as described by Kohlberg's theory of levels of moral development?

preconventional

When examining a client who has abdominal pain, a nurse should assess

the symptomatic quadrant last.

A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions?

vesicles

After instructing a pregnant client about third trimester edema, the nurse determines that the client needs further instruction when the client makes which statement?

"Swelling in my hands and face is to be expected."

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond?

"You must wait at least 1 year before becoming pregnant again."

A primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which statement would be the nurse's best response?

"You should abstain from drinking alcoholic beverages."

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action?

Hold the breath throughout the length of the contraction.

An older adult is being discharged following a repair of an inguinal hernia. The client is independent and lives alone, but the client's family lives 60 miles from the client's house. When at home, the client is to cleanse and inspect the incision for signs of infection. The client and family are able to read and understand written instructions. When giving discharge instructions, what should the nurse do? Select all that apply.

Explain the instructions to the client. Ask the client to demonstrate the procedure. Provide written instructions for the client.

The nurse is counseling a client with osteoporosis about dietary choices to slow bone loss. What foods should the nurse teach the client to avoid?

Foods and beverages high in caffeine

During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

The client will need Rh immunoglobulin injection within 72 hours.

A client has cerumen build-up in the ear. What should the nurse instruct the client to do? Select all that apply.

Wash the external ear with a washcloth. Instill cerumenolytic drops in the ear canal. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.

After receiving information on various forms of birth control, a young couple decides to use a barrier method because they would like to try and conceive in 1 to 2 years. Which barrier method uses a rubber barrier to hold spermicide against the cervix?

a diaphragm

The nurses discusses appropriate iron-rich food selections with the parent of an 11-month-old infant with iron deficiency anemia. The nurse determines that teaching has been successful when the parent verbalizes that she will include which foods in the child's diet?

eggs, fortified cereals, meats, and green vegetables

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?

"I will place my baby in a supine position for sleep during the first year."

The public health nurse is teaching a prenatal class about tobacco smoke during pregnancy. Which comment made by one of the class members demonstrates that the teaching was effective?

"If I continue to smoke during pregnancy, my baby could be born small."

A pregnant client with diabetes mellitus is at risk for having a large-for-gestational-age neonate because:

insulin acts as a growth hormone on the fetus.