Lesson 3 part 1
The nurse is providing education to a client in her first trimester of pregnancy. Which statement indicates the client needs further education? "It is normal to have some fatigue." "I will continue to exercise as directed." "I will schedule visits with my health care provider only as needed." "I will continue to take my prenatal vitamins as directed."
"I will schedule visits with my health care provider only as needed." A pregnant client must adhere to a strict health care visit protocol. The nurse must provide this information and set up an appointment schedule for the client. Adhering to the appointment schedule with the health care provider can help ensure a healthy pregnancy and can identify and prevent complications.Fatigue is normal for a pregnant client to experience along with other symptoms such as, but not limited to, nausea, frequent urination and breast sensitivity. Pregnant clients should continue to take their prenatal vitamins to help prevent complications and may remain on an exercise schedule as discussed with their health care provider.
A client who has just given birth asks the nurse what an Apgar score means. The correct response by the nurse should be: "The score indicates that your newborn may have future complications." "The score is for the physician and not something you need to worry about." "The score is a general overview of how well your newborn is doing." "The score indicates that your newborn will not have future health complications."
"The score is a general overview of how well your newborn is doing." The Apgar score gives the health care team a general overview of how well the newborn is acclimating. It is not a predictor of future problems or lack thereof. Although the score is most meaningful to the health care team, the role of the nurse is to educate and answer client questions as appropriate.
A woman who is 15 weeks pregnant verbalizes concern to the nurse about weight gain during pregnancy. Which statement indicates a correct understanding of weight changes for a woman during the second trimester? "You should gain about one pound each week." "Try to gain as little as possible during this trimester." "Expect to gain between 3 to 5 pounds during this trimester." "Don't worry about weight gain. You are eating for two."
"You should gain about one pound each week." Women with a normal body mass index (BMI) should expect to gain between 25 to 35 pounds (11.34 to 15.88 kg) during pregnancy. Women who are underweight will need to gain more (up to 40 pounds (18.14 kg)) while women who are obese should gain less (between 10 to 20 pounds (4.54 to 9.07 kg)). During the first trimester, women should gain between 3 to 5 pounds (1.36 to 2.27 kg). In the second and third trimesters, women should gain a pound a week. Weight gain should be steady and gradual, with a focus on healthy eating habits. Dieting and binge eating should be discouraged.
The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy? Resolving any fears related to giving birth. Viewing the fetus as a separate and unique being. Accepting the loss of physical intimacy. Accepting physical changes related to pregnancy.
Accepting physical changes related to pregnancy. During the first trimester, the developmental focus is directed toward accepting the pregnancy and adjusting to pregnancy-related physical changes and discomforts. It is expected that the client will have some ambivalence during the first trimester, but the client can maintain physical intimacy with her partner if she wishes, including sexual intercourse. Looking at the fetus as a separate being and overcoming fears related to giving birth will occur in the third trimester, closer to the due date.
The nurse is interviewing a client to verify pregnancy. What information from the client will provide presumptive findings? (Select all that apply.) Cervical changes Fatigue Breast sensitivity Amenorrhea Nausea Uterine changes
Amenorrhea Nausea Uterine changes A client typically will report breast sensitivity, missed period, nausea and fatigue (this is not a complete list of symptoms pregnant women could report). Uterine and/or cervical changes cannot be reported by the client but will be a finding of the health care provider.
Which of the following interventions should the nurse include in the plan of care for a client who recently experienced a fall at home? (Select all that apply.) Provide soft flooring by placing throw rugs throughout the home. Avoid using chairs with armrests to reduce the risk of injury. Insert an indwelling urinary catheter to reduce incontinence episodes. Apply nonslip strips to the bottom surface of the shower. Monitor blood pressure when lying down, sitting and standing. Ensure the room lighting is adequate and remove clutter in the room.
Apply nonslip strips to the bottom surface of the shower. Monitor blood pressure when lying down, sitting and standing. Ensure the room lighting is adequate and remove clutter in the room. The nurse should ensure that the client's home environment is safe (i.e., has appropriate lighting, is free of clutter and unnecessary furniture and throw rugs). There is no indication for an indwelling catheter for this client, and unnecessary urinary catheterization is a risk factor for catheter-associated urinary tract infections (CAUTIs). Chairs with armrests can reduce the risk of falls, since the armrests provide support and help prevent client from sliding off the chair. Monitoring blood pressure for orthostatic hypotension can reduce the risks of falls. Nonslip strips and grab bars can improve safety in the bathroom and reduce the risk of falls.
During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next? Palpate the area. Measure the length of the mass. Percuss the area. Auscultate the area.
Auscultate the area. A pulsating mass at the periumbilical area is indicative of an abdominal aortic aneurysm (AAA). Auscultation of the abdomen should be done next to check for a bruit, which will further confirm the possible presence of an AAA. The other actions are contraindicated because causing pressure to the area through palpation or percussion may cause the aneurysm to leak or rupture. Measuring the area would not provide any useful data.
A hospitalized, school-age child with a spica cast says to the nurse "I am bored." Which type of activity would be most appropriate for the nurse to implement for this child? Unlimited television time Jump rope Board games Push-pull toys
Board games School-age children enjoy activities which promote physical growth, intellectual ability and fantasy. With the spica cast, vigorous physical activity will be limited. Quiet activities include reading, arts and games. The nurse should discourage unlimited television or electronic screen time. Push-pull toys would be more appropriate for younger children, such as toddlers.
A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.) Color of bowel movements Frequency and amount of naproxen used Bruising Tingling or numbness in the extremities Photophobia
Color of bowel movements Frequency and amount of naproxen used Bruising Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen can cause gastrointestinal (GI) irritation and bleeding. The client's vital signs and pale skin color indicate possible hypovolemia (tachycardia and hypotension) secondary to blood loss. The nurse should inquire about other findings that may indicate bleeding, e.g., black tarry stools and bruising. The nurse should also determine the amount of naproxen the client has been taking. Tingling, numbness or photophobia are not side effects seen with naproxen use or overuse.
A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? Confirm that the client's hearing is intact. Observe the client while performing an activity. Ask the client to state his date of birth. Ask the client to name the current U.S. president.
Confirm that the client's hearing is intact. A baseline evaluation of a client's neuro-sensory status should include checking for hearing loss. The client's inability to hear may cause them to answer questions incorrectly, which can be misinterpreted by the nurse as short-term memory loss or confusion. The other actions should then also be implemented to further evaluate the client's cognitive and mobility status.
The nurse is reviewing the client's medical record and notes that the client has been taking an oral contraceptive for several years. For which potential complications should the nurse monitor the client? (Select all that apply.) Osteoporosis Depression Colon cancer Anemia Breast cancer Deep Vein Thrombosis (DVT)
Depression Breast cancer Deep Vein Thrombosis (DVT) Oral contraceptives contain both advantages and disadvantages for clients. Advantages include shortening menstrual cycles, decreasing anemia and protecting against bone loss. Clients have decreased risks for ovarian, colorectal and endometrial cancers. Potential complications include increased risks for breast cancer, depression and a DVT. Women who smoke may have an increased risk for myocardial infarction, stroke and hypertension.
The clinic nurse is meeting with a client who wants to talk about her and her partner's plan for a future pregnancy. What information is important for the nurse to give to the client? Folic acid should be started before the client has a confirmed pregnancy. All prescribed medications should be continued without concerns. Immunizations should be avoided at this time. Only the women's medical history should be considered.
Folic acid should be started before the client has a confirmed pregnancy. Women should start to take folic acid prior to pregnancy to decrease the risk of neural tube defects. Preconception care involves a complete review of both partners' medical history. Medications, supplements, nutrition and psychosocial concerns should be reviewed. Risk factors which impact pregnancy, such as alcohol, drug use, medications, infections, etc., should be identified and avoided. Immunizations should be reviewed and encouraged before pregnancy.
A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs? Identify community resources. Identify the client's learning needs. Assist with meal planning. Evaluate the home for safety hazards.
Identify the client's learning needs With a focus on health promotion, the nurse should first identify any learning needs. This also represents the first step in the nursing process. Once the client's learning needs are identified, the nurse will be able to develop or assist with developing a plan of care that meets the client's individual needs. Then the nurse should perform a home safety check, identify community resources for the client and, if needed, assist with meal planning.
The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure? Evaluate the client's understanding of appropriate foot care. Arrange for referral to a diabetic educator. Involve the client in making decisions. Schedule regular visits to monitor wound healing.
Involve the client in making decisions Although all these interventions may benefit the client, the involvement of the client in making health care decisions is the most important intervention to improve meeting desired goals and outcomes. The client will be more motivated to adhere to the nurse's recommendations if they are involved in the process of setting priorities and making decisions.
The nurse is caring for a patient who has just experienced a spontaneous abortion (miscarriage). What action should the nurse implement first? Monitor the client for bleeding and medicate for pain Provide information on birth control methods Refer the client to a grief counselor Administer Rho(D) to the client
Monitor the client for bleeding and medicate for pain The nurse's priority is to address the client's physical needs (A-B-C) according to Maslow's hierarchy of needs. The nurse must assess and monitor bleeding and be prepared to act if there is a complication such as a hemorrhage. The other actions are also part of the nurse's plan/implementation but are not the initial priority.
During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform? Says several words Uses pincer grasp Sits without support Drinks from a cup
Sits without support The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months.
The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention? Weight reduction Smoking cessation Increasing physical exercise Stress management
Smoking cessation Stopping smoking is the highest priority for clients at risk for cardiac disease because of the effects of smoking on the arteries, including atherosclerosis and vasoconstriction. The other interventions are also important, modifiable actions to prevent cardiovascular disease (CVD). However, smoking tobacco products is widely considered the greatest risk factor for developing CVD (as well as other diseases).
The nurse is providing information to a pregnant client about the potential risks of an amniocentesis. Which risk factors shall the nurse include? (Select all that apply.) Ectopic pregnancy Spontaneous abortion Premature rupture of membranes Preeclampsia Increase in blood glucose levels Preterm labor
Spontaneous abortion Premature rupture of membranes Preterm labor During an amniocentesis, amniotic fluid is removed from the uterus through the insertion of a hollow needle through the abdominal wall and into the uterus. Reasons include genetic testing, fetal lung testing, and removal of excess amniotic fluid (polyhydramnios). Amniocentesis carries various risks, including: leaking amniotic fluid, rupture of amniotic membrane, miscarriage or spontaneous abortion, preterm labor, needle injury to the fetus, Rh sensitization and infection.
The nurse is collecting baseline data on a 14-month-old child during a wellness visit in the primary care provider's office. Which of the following measurement methods are correct? (Select all that apply.) The nurse counts the child's pulse by placing one finger on the radial artery for a full minute. The nurse places the child on an infant platform scale in either a sitting or supine position. The nurse measures the child's chest circumference by placing the measurement tape around their chest at the nipple line. The nurse measures the child's height while the child stands against the wall supported by the parent. The nurse places the tape measure around the child's head at the widest part of the frontal and occipital bones.
The nurse places the child on an infant platform scale in either a sitting or supine position. The nurse measures the child's chest circumference by placing the measurement tape around their chest at the nipple line. The nurse places the tape measure around the child's head at the widest part of the frontal and occipital bones. Data collection methods should be correct for the age of the client. Data collection methods for children under the age of two are different than those for older children. A healthy 14-month-old child who is developing normally may prefer to sit on the scale than to be laid on the scale but their height should still be measured while laying down. A toddler's head and chest circumference are measured with a tape measure. The head circumference is measured at the widest point of the frontal and occipital bones, while the chest circumference is measured at the nipple line. An infant or toddler's pulse is counted apically, not radially.
Which of these are examples of primary prevention activities? (Select all that apply.) Vaccination Rehabilitation An exercise class Cholesterol screening Car seat installation education Breast self-exam
Vaccination An exercise class Car seat installation education Engaging in an exercise class, correctly installing a child safety or car seat and getting vaccinations are considered primary prevention activities. Rehabilitation falls under tertiary prevention. Cholesterol screening and breast self-exam are secondary prevention interventions.
The nurse in a primary care provider's office is collecting data on lifestyle choices and activities of daily living (ADLs) from an older adult client. Which of the following statements by the nurse would be appropriate? (Select all that apply.) "Didn't you quit smoking last year?" "How do you spend your time on a typical day?" "Tell me what you eat on a typical day." "Do you feel unsafe at home?" "Are you still trying to lose weight?" "How many glasses of alcohol do you drink per day or per week?"
"How do you spend your time on a typical day?" "Tell me what you eat on a typical day." "How many glasses of alcohol do you drink per day or per week?" Data collection on ADLs and lifestyle choices measures a client's ability to provide self-care and maintain their health and should be done in a way that positively reinforces what the client is doing correctly. It also collects general information on the client's overall health status. It should be done in a clear, non-judgmental manner. Asking if someone feels unsafe can be unclear. The nurse should use open-ended questions to obtain as much information as possible.
A woman comes to a clinic to discuss contraceptive options. Which statement by the client indicates to the nurse a need for additional teaching? (Select all that apply.) "I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection." "Not having any type of sexual intercourse is the only way to be sure I won't get pregnant." "Using an intrauterine device (IUD) increases my risk for a pelvic infection." "My diaphragm will work no matter how much weight I gain." "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential pregnancy." "I should stop smoking before starting an oral contraceptive."
"I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection." "My diaphragm will work no matter how much weight I gain." "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential pregnancy." Women who smoke while taking oral contraceptives have an increased risk for a myocardial infarction, stroke and hypertension, so smoking cessation should be encouraged. Diaphragms should be refitted after pregnancy and pelvic surgery and whenever the client's weight changes. Medroxyprogesterone acetate (Depo-Provera) injections are effective for three months. Cervical caps, sponges and IUDs increase the risk for pelvic infections. Vaginal rings may fall out and alternative contraceptive methods should be used. Abstinence is the only method that provides complete protection from pregnancy.
