Health Promotion and Maintenance NCLEX
A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan?
Take a blood glucose test before exercising.
The nurse should include which item in a list of the most helpful foods for a vegan client wishing to increase foods high in vitamin A?
carrots
The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk?
yogurt
The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction?
"It is best to do TSE first thing in the morning before a bath or shower."
The nurse is preparing to provide instructions to a new mother regarding cord care for a newborn infant. Which instructions would the nurse provide? Select all that apply.
1,4
tThe nurse is caring for a 14-year-old girl who is hospitalized and has been placed in traction using Crutchfield tongs. The child is having difficulty adjusting to the prolonged hospital confinement. Which nursing action would be appropriate to meet the child's needs?
Let the child wear her own clothing when friends visit.
A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?
Allow the client to interact with others in his or her (adolescent) same age group.
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?
Palpating for peripheral edema
Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother?
Peanut butter and jelly sandwich and glass of 2% milk
The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if one of the students states that which action should be performed?
Roll the testicle between the thumb and forefinger.
The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing?
Tertiary level
A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's highest priority at this time is to perform which action?
Thoroughly dry the newborn.
The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?
Uses a cup to drink
The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide?
Wash the breasts with warm water and keep them dry.
The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client?
Wear a supportive brassiere continuously for 72 hours.
A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint?
Chronic kidney disease
The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)?
32 cm
A 6-month-old infant is admitted to the hospital. The nurse weighs the infant and notes that the infant's weight is 14 pounds. Which statement by the mother indicates that further teaching is needed?
"I will have to increase his milk intake because he is not gaining enough weight."
The mother of a toddler informs the nurse that her child has frequent temper tantrums. The nurse should instruct the mother to implement which measure to deal with the temper tantrums
Ignore the behavior.
The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client?
Intolerance for sound levels that do not bother other people
A community health nurse is providing an educational session on cancer of the cervix for women living in the community. The nurse informs the community residents that which is an early sign of this type of cancer?
Irregular vaginal bleeding or spotting
A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart?
July 26, 2019
The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure?
Limit caffeine intake.
The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain?
Nail bed pressure
The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)?
Pulsation between the umbilicus and the pubis
After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds?
Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants
The nurse is documenting the findings of a physical examination in a client's record. Which findings should the nurse determine to be objective data?
The client has a rash on the chest and arms.
a just delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism?
Evaporation
The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease?
caused by tick bite
A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms?
eating dry crackers before arising
the nurse provides dietary instructions to a client at risk for hypokalemia about which foods are high in potassium and should be included in the daily diet. The nurse should tell the client that which fruit is highest in potassium?
kiwi
The community health nurse has conducted a teaching session for community members about the risk factors for laryngeal cancer. Which statement by a person attending the session indicates that teaching was effective?
"Exposure to airborne carcinogens can cause this type of cancer."
The nurse is providing instructions to the mother of a child with human immunodeficiency virus infection regarding immunizations. Which statement by the mother indicates an understanding of the immunization schedule?
"Family members in the household need to receive the influenza vaccine."
The nurse has given instructions to a client with hepatitis about postdischarge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement?
"I can resume a full activity level within 1 week."
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates a need for further teaching?
"I cannot exercise because of the negative effects on insulin production."
the nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge?
"I don't have anyone to help me with doing heavy housework at home."
The nurse has given instructions about Kegel exercises to a female client with a cystocele. The nurse determines that the client needs further instruction if she makes which statement?
"I should begin voiding and then stop the stream, holding residual urine for an hour."
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?
"I should wash my nipples daily with soap and water."
A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures?
"I should wear underwear with a cotton panel liner."
The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method?
"I should weigh the perineal pad before and after use and note the amount of time between each pad change."
The nurse is providing anticipatory guidance to the mother of a 10-month-old child. The mother asks how soon her daughter will be able to receive the chickenpox (varicella) vaccine. What is the best nursing response?
"She can receive it when she is 12 months old."
A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure?
"The procedure is performed using artificial insemination of sperm instilled through the vagina."
A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching?
"Visitors are not allowed for 1 month."
The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client?
"You can read at a distance of 20 feet (6 meters) what a person with normal vision can read at 30 feet (9 meters)."
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.
1, 2, 4
The nurse is preparing to interview a client to collect data about the client's health history. The nurse should take which actions to make sure that the physical environment is ready? Select all that apply.
1, 2, 5
The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply.
1,2,3
the nurse is participating in a prostate screening clinic for men. Which complaints by a client are associated with prostatism? Select all that apply.
1,2,3,5
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.
1,2,3,6
Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply
1,2,4,5
The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply.
3,5
Which individuals are most likely to be at risk for development of psoriasis? Select all that apply.
2,3,4
The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply.
2,3,4,6
The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.
2,3,5
The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.
2,3,5
The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply.
2,4,5,6
The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply.
2,5,6
The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply.
3,4,5,6
A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used.
4. Stands 2 to 3 feet in front of and faces the client 3. Asks the client to report when object is first noted 2. Examiner covers eye opposite to the eye covered by the client 3. Asks the client to report when object is first noted 5. The examiner brings in an object gradually from periphery
The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time? Select all that apply.
5,6
The clinic nurse has conducted a health screening clinic to identify clients who are at risk for cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at lowest risk for developing this type of cancer?
A single white client
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test?
A tuning fork
The community health nurse conducts a health promotion program for community members regarding testicular cancer. The nurse determines that further information needs to be provided if a community member states that which is a sign of testicular cancer?
Alopecia
A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps?
Apply heat to the affected area.
The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action?
Assess the client's readiness to learn
On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?
At 1 minute after birth and 5 minutes after birth
The nurse at a well-baby clinic is assessing the language and communication developmental milestones of a 4-month-old infant. On the basis of the age of the infant, what should the nurse expect to note as the highest-level developmental milestone?
Babbling sounds
The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?
Crayons and a coloring book
During a woman's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What should be the nurse's next intervention?
Document findings in the electronic health record.
the nurse checks the respirations of a newborn who was just delivered. The respiratory rate is 40 breaths/minute. Which intervention is most appropriate related to this finding?
Document the findings in the electronic health record.
The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take?
Document the findings.
The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid?
Dried peas
The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure?
Drink 8 glasses of water per day.
The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction?
Hold the gum between the cheek and teeth periodically.
When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?
Massage distended areas as the infant nurses.
The nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant?
Periodic well-baby examinations
The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action?
Place the fetal heart monitor on the client in order to do a nonstress test (NST).
the pediatric nurse is caring for a hospitalized toddler. What does the nurse determine is the most appropriate play activity for the toddler?
Playing with a push-pull toy
The clinic nurse has provided instructions about dental care for toddlers to the mother of a 2-year-old child. Which statement, if made by the mother, indicates a need for further instruction?
Proper dental care is not necessary for a toddler until the permanent teeth erupt."
The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education?
Properly glazed pottery
The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the ear drops correctly, the mother needs to take which action?
Pull down and back on the earlobe and direct the solution toward the wall of the canal.
An infant is being seen in the pediatrician's office for a 2-month-old well-child visit. The nurse encourages the mother to allow the infant to suck on a pacifier during a routine immunization. The nurse explains to the mother that the child is at which stage of Piaget's cognitive development?
Sensorimotor development
The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?
Snellen chart
The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the rooting reflex?
Stimulate the perioral cavity with a finger.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?
The client's last baby weighed 10 pounds at birth.
The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?
The functional status of the vestibular apparatus in the inner ear
Which would be the highest expected growth and development occurrence at 12 months of age for an infant who has had appropriate growth assessed at each well-child visit?
Walks holding on to someone's hand
The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?
mitral area
A nurse is assessing the status of jaundice in a child with hepatitis. Which anatomical areas will provide the best data regarding the presence of jaundice? Select all that apply.
sclera nail beds mucous membranes
The community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which is a risk factor for this disorder?
A diet low in vitamin D
The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?
A wisp of cotton
Which client is most at risk for developing a Candida urinary tract infection (UTI)?
A young woman on antibiotic therapy
A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client?
Retesting rubella titer during pregnancy
The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which instruction should the nurse provide to the mother?
The child and the siblings will need to receive inactivated polio vaccine.
The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly?
The client begins to wash the newborn by starting with the eyes and face.
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?
The client is measuring normal for gestational age.
The nurse instructs a client with diabetes mellitus who takes insulin about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse should inform the client that a blood glucose level of which value indicates hypoglycemia?
60
The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client?
You need to perform BSE on the same day every month."
The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent?
The inactivated influenza vaccine will be given yearly.
