Health Promotion Questions

A client who had the left hand amputated after a traumatic injury is being fitted for a permanent prosthesis. What should the nurse teach the client about the most important factor for successful adaptation to the permanent prosthesis? Muscles in the upper arm must be developed. Dexterity in the other extremity must be achieved. Shrinkage of the residual limb must be completed. Adjustment to the altered body image must be accomplished.

3.

The nurse gently performs Leopold maneuvers on a client with a suspected placenta previa. What does the nurse expect to find during this assessment? Firm engagement of the fetal head Difficulty palpating small fetal parts A high, floating fetal presenting part A hard and tetanically contracted uterus

3.

Which function of a client's eyes ensures formation of a single image of close objects being seen? Mydriasis Convergence Accommodation Pupillary constriction and dilation

2. Convergence action of the eyes ensures that only a single image of close objects is seen. Mydriasis is pupil dilation when exposed to reduced light or looking at a distance. The process of maintaining a clear visual image when the gaze is shifted from a distant to a near object is known as accommodation. Pupillary constriction and dilation control the amount of light that enters the eye.

Which cytokine stimulates the liver to produce fibrinogen and protein C? Interleukin-1 Interleukin-6 Thrombopoietin Tumor necrosis factor

2. Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies.

A nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. What is the volume of solution the nurse should prepare? 150 to 250 mL 250 to 350 mL 300 to 500 mL 500 to 750 mL

2. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. The nurse should prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.

A client is found to have groups of isolated erythematous pustules on the scalp. Which statement made by the client is associated with the skin infection present in the client? "I have had a fever." "I have no discomfort." "I have a lot of itching, stinging, and pain." "I have cracks at the corner of my mouth."

2. The presence of isolated erythematous pustules in groups on the scalp indicates folliculitis. A client with folliculitis may not feel any discomfort. A client with cellulitis has a fever. A client with herpes simplex infection feels itching, stinging, or pain. A client with candidiasis may have cracks at the corner of the mouth.

A pediatric client reports difficulty breathing and swallowing and has a sore throat, headache, and fever. The nurse observes a grayish yellow membranous patch near the tonsils. What disease does the nurse infer from these findings? Mumps Pertussis Diphtheria Pneumonia

3. Diphtheria is caused by Corynebacterium diphtheriae. Symptoms include a sore throat, fever, and headache along with gray or dirty-yellow membrane patches. Mumps is a viral disease that primarily affects the parotid glands. It is accompanied by local pain, tenderness, fever, and swelling. Pertussis, also known as whooping cough, is caused by Bordetella pertussis. Symptoms include rhinorrhea, mild fever, and a persistent cough. Pneumonia is a lung disease; symptoms include a cough and chest pain.

A client with acute kidney failure becomes lethargic and fatigued. Upon reviewing the client's medical record, which finding does the nurse determine is the most likely cause of this behavior? Hyperkalemia Hypernatremia A limited fluid intake An increased blood urea nitrogen level

4.

While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client? Multiple choice question Pallor Vitiligo Cyanosis Erythema

4. Erythema occurs due to an increased visibility of oxyhemoglobin, which is caused by increased blood flow. Pallor is caused by a reduced amount of oxyhemoglobin or a reduced visibility of oxyhemoglobin. Vitiligo is a pigmentation disorder caused by autoimmune diseases. Cyanosis is a bluish discoloration of the skin around the lips; this occurs due to an increased amount of deoxygenated hemoglobin in the blood.

A 65-year-old client tells the nurse, "I see some particles that float within my field of vision." What may be the cause of this condition Opacities in the lens Dilator muscle atrophy Atrophy of nerve fibers Liquefaction and detachment of the vitreous membrane

4. Increased reports of floaters are associated with liquefaction and detachment of the vitreous membrane. Opacities in the lens may result in night vision impairment and glare. Dilator muscle atrophy results in a slower recovery of the pupil size after light stimulation. Atrophy of the nerve fibers may result in decreased corneal sensitivity and corneal reflexes.

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns? Provide a diet high in sodium. Limit caloric intake to decrease the work of the body. Reduce protein intake to avoid overtaxing the kidneys. Administer the prescribed intravenous fluid with the added vitamin C.

4. Vitamin C is essential for wound healing. It provides a component of intercellular ground substance that develops into collagen and is necessary to build supportive tissue. To prevent excessive fluid retention, which will increase the cardiovascular workload, sodium intake should be regulated. Decreasing calories will promote catabolism of body tissue; caloric need is increased. Protein intake should be increased to help repair damaged tissue.

The nurse is caring for a client after a right pneumonectomy for cancer. As part of the assessment, the nurse palpates the client's trachea. What is the rationale for this assessment? A mediastinal shift may have occurred. Subcutaneous emphysema may be present. Tracheal edema may lead to an obstructed airway. The cuff of the endotracheal tube may be underinflated.

1.

Which muscle helps in moving the eye diagonally downward towards the middle of the head? Lateral rectus muscle Medial rectus muscle Inferior rectus muscle Inferior oblique muscle Superior oblique muscle

2 and 3. The inferior rectus muscle together with the medial rectus moves the eye diagonally downward towards the middle of the head. The lateral rectus muscle together with the medial rectus muscle holds the eye straight. The medial rectus muscle helps in turning the eye towards the nose. The inferior oblique muscle will pull the eye upward. The superior oblique muscle pulls the eye downward.

A nurse is caring for a 5-year-old child who is a victim of physical abuse. Which interventions are appropriate while talking to the child to help reveal the abuse? Asking about the family's social or legal problems, if any Discussing the body parts using words the child will understand Telling the child that it is not the child's fault and no one is going to blame the child Telling the child that reporting the abuse to the nurse is the right thing to do Allowing the child to talk in the presence of the family members to minimize fear

2, 3, and 4. While asking the preschooler to reveal abuse, the nurse should discuss the body parts using words that the child will understand. The nurse should tell the child that it is not the child's fault and no one is going blame the child. The child should also be told that it is a good thing to report about the incident to the nurse, as it is required by law that the nurse report the incident. The nurse should limit the interview to the child's physical and mental health concerns and not ask about the family's social or legal problems. Physical abuse can also be caused by parents; therefore a private time and place should be provided for the abused child to talk.

During the postpartum period increased cardiac output with tachycardia is expected in the client with existing heart disease. This knowledge should motivate the nurse who is caring for this client to monitor her for what? Irregular pulse Respiratory distress Hypovolemic shock Increased vaginal bleeding

2.

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment? Decreased breath sounds Elevated serum troponin I Decreased creatine kinase-MB (CK-MB) Elevated brain natriuretic peptide (BNP) level

2. Elevations of troponin I levels are indicative and specific for cardiac muscle damage. Decreased breath sounds would indicate a pulmonary problem. An increase in CK-MB would indicate MI. Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction.

A healthcare provider is planning to perform a procedure on an 8-year-old child. How can the nurse best meet the child's developmental needs before the procedure? By arranging to have one of the child's parents present By allowing the child to handle the equipment that will be used By explaining to the child what will happen during the procedure By having the child talk to a child who has recently undergone the same procedure

2.Allowing the child to handle the equipment that will be used will permit the child to investigate and become familiar with the equipment, alleviating anxiety. Arranging to have one of the child's parents present may be supportive but is not always possible; some parents are more anxious than the child, and anxiety can be contagious. Explaining to the child what will happen during the procedure may be beyond the comprehension of the average 8-year-old child and will do little to reduce anxiety. Having the child talk to a child who has recently undergone the same procedure is beyond the ability of another 8-year-old child and will do little to reduce anxiety in the child scheduled for the procedure.

A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? Decreased tremors Increased hours of sleep Weight loss during next 2 days More rapid heart rate within 2 days

3. Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failure. Tremors are not typical in infants with heart disease. Tremors are related to central nervous system irritability. If the infant's condition improved, energy would increase and sleeping needs would decrease. Tachycardia is a sign of congestive heart failure. The purpose of the cardiotonic is to slow the heart rate.

The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking? Multiple choice question "The pain is usually present in my fingers and knees." "I observed swelling and redness near the pain area." "I feel the pain in each and every joint of my hands and legs." "I run for 30 minutes every day; this exercise increases my pain."

4.

Which area is most common for the occurrence of the carcinoma represented in this image? Sun-exposed areas Sites of chronic irritation Area of the backs of hands Place where moles are evident

4. The image signifies melanoma. These pigmented cancers may arise in melanin-producing epidermal cells. Melanoma most commonly occurs at the place where moles or birthmarks are evident. Basal cell carcinomas include a pearly papule with a central crater that mostly occurs in the sun-exposed areas. The sites of such chronic irritation as scars, irradiated skin, burns, and leg ulcers may be found with squamous cell carcinomas. Actinic keratosis may develop on the areas of the back of the hands.

While caring for a client who had an accident, the nurse suspects injury to the frontal lobe. Which statements by the client may support the nurse's conclusion? "I am unable to play the piano." "I am unable to hear properly." "I am unable to move my eyes." "I am unable to concentrate on anything." "I am unable to taste any flavors in the foods I eat."

1, 3, and 4. Functions of the frontal lobe include voluntary eye movements, playing musical instruments and the ability to concentrate. Therefore, injury to the frontal lobe impairs these functions. Injury to the temporal lobe causes loss of auditory function. Injury to the parietal lobe causes loss of taste sensation.

A client with osteomyelitis has a slow rate of healing. Which factors can contribute to reduced healing in the client? Diabetes Cataract Smoking Dermatitis Alcoholism

1, 3, and 5. Diabetes causes narrowing of blood vessels, thereby causing diminished blood supply to the affected organ or tissue; clients with diabetes have a slow healing rate. Intake of tobacco through smoking may reduce the blood supply to the affected area, thereby slowing down the healing process. Alcohol abuse reduces the amount of nutrients and vitamins required for muscle growth, thereby affecting the healing process. Cataract is a disease of the eye and does not affect the musculoskeletal system. Similarly, dermatitis is a skin condition that does not affect the musculoskeletal system.

What assessments should be done before administering uterine stimulants to induce labor? The cervix must be ready for labor induction. Sympathomimetic drugs can be administered. An intrauterine device for birth control can be used. The fetal heart rate and contractions should be documented. The mother's blood pressure, pulse rate, and respirations should be assessed.

1, 4, and 5. Cervical ripening is important for the induction of labor and delivery of the fetus. The fetal heart rate should be documented to assure the safety of the fetus. The mother's vital signs should be monitored regularly to detect medical conditions. Sympathomimetic drugs should be avoided because they may cause severe hypertension. The presence of an intrauterine device may cause an inflammatory response in the uterus.

The nurse is examining a child living in foster care who has not had access to vision screening. The nurse suspects that the child is at high-risk of developing amblyopia. Which statement is true? The child is around 6 years of age and has untreated strabismus. The child is around 3 years of age and has uncorrected strabismus. The Hirschberg test performed on this child shows that the light falls symmetrically within each pupil. The alternate cover test performed on this child shows that shifting the cover from one eye to the other causes the eye to move.

1. In strabismus, or cross-eye, one eye deviates from the point of fixation. If strabismus is not detected and corrected by 4 to 6 years of age, blindness from disuse, known as amblyopia, may result. So, the 6-year-old child with untreated strabismus is at risk for developing amblyopia. If a 3-year-old child is found to have strabismus, there is still time to treat it so the child does not develop amblyopia. For the Hirschberg test, commonly used to detect misalignment, a flashlight or the light of the ophthalmoscope is shone directly into the client's eyes from a distance of about 40.5 cm (16 inches). If the eyes are orthophoric, or normal, the light falls symmetrically within each pupil. In the alternate cover test, occlusion shifts back and forth from one eye to the other and movement of the eye that was covered is observed as soon as the occluder is removed while the child focuses on a certain point. If normal alignment is present, shifting the cover from one eye to the other will not cause the eye to move. Neither of these two results indicates a high-risk of developing amblyopia.

The nurse teaches the client about foods to help prevent constipation after pelvic surgery. Which foods selected by the client indicate that the teaching is understood? Ripe bananas Milk products Green vegetables Steamed cabbage Whole grain bread

3, 4, and 5. Green vegetables and steamed cabbage contain fiber, which promotes defecation. Whole grain bread contains fiber, which promotes defecation. Bananas have a binding effect and promote constipation. Milk and milk products have a binding effect and promote constipation.

What should the nurse place in temporary shelters without running water that were created for disaster victims to use for toileting? Trash bags Bottled water Hand sanitizer Soap and paper towels

3. In the absence of water, hand sanitizer should be placed in the temporary shelters being used as bathrooms. The purpose of the hand sanitizer is to perform hand hygiene after toileting. Trash bags would not be appropriate since there is no running water in the shelters. Bottled water would be better used for drinking and not for hand hygiene. There is no running water, so soap and paper towels would not be appropriate.

A client who had an open reduction and insertion of a prosthesis for a fracture of the femoral neck is stable after surgery and is returned to the orthopedic unit. What is most important for the nurse to do when positioning this client? Maintain both legs in abduction. Keep both legs in functional body alignment. Avoid placing the client in the supine or prone position. Prevent adduction and external rotation of the affected extremity.

4. Adduction may cause dislocation of the new prosthesis, and external rotation increases tension on the suture line. Only the operated leg needs to be kept abducted. Keeping both legs in functional body alignment positions the affected leg too close to the midline and increases the danger of hip dislocation. The supine position is permitted as long as the affected leg is abducted and external rotation avoided, which help keep the prosthesis firmly in the acetabulum. The prone position is not advised, because it puts excessive stress on the operative site.

The mother of an adolescent reports that her child does not eat properly, performs strenuous physical exercise, and is very introverted. What nursing interventions would be appropriate? Monitoring the adolescent's fluid and electrolyte status Monitoring the adolescent for disturbances in family interactions Counseling the adolescent about good personal hygiene and sanitation Checking for evidence of self-induced vomiting Developing a mutually agreeable targeted daily caloric intake goal

1,2,4, and 5

What should the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? A low-phenylalanine diet is required. Phenylalanine is not necessary for growth. Phenylalanine can be administered to correct the deficiency. A substitute for phenylalanine is an increased amount of other amino acids.

1. Reducing dietary phenylalanine helps prevent brain damage. The PKU diet is planned to maintain the serum phenylalanine level at 2 to 8 mg/100 mL. Phenylalanine is essential for growth and development of the brain. Administering phenylalanine is contraindicated. There is no substitute for phenylalanine, which is one of the essential amino acids.

A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. What does the nurse determine is the probable cause of this response, and what is the treatment? Intestinal edema after surgery; apply ice Presurgical decrease in fluid intake; encourage fluids Absence of gastrointestinal motility; continue to monitor Effective functioning of nasogastric suction; irrigate stoma

3. The colostomy starts functioning when peristalsis returns. Intestinal manipulation and the depressive effects of anesthesia and analgesics cause absence of gastrointestinal motility; this is an expected response, so continue to monitor. Edema will not interfere totally with peristalsis; there should be some output; ice will damage the stoma. A presurgical decrease in fluid intake will not influence gastric motility 24 hours later. A nasogastric tube decompresses the stomach; it does not directly influence intestinal motility at this time; irrigation is not necessary.