N490 HESI REMEDIATION EAQ: Health Promotion & Maitenance

At which stage of Kohlberg's theory would a child exhibit fear of punishment? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

1 Rationale: According to Kohlberg's theory of moral development, at stage 1 a child is afraid of punishment. At stage 2, the child recognizes that there is more than 1 correct viewpoint. At stage 3, an individual seeks the approval of and maintains the expectations of one's immediate group. At stage 4, an individual expands focus from a relationship with others to societal concerns.

Which age-appropriate behaviors would the nurse expect in a 2-year-old child at play? Select all that apply. One, some, or all responses may be correct. 1 Is possessive of toys 2 Follows simple directions 3 Can play simple card games 4 Enjoys playing with other children 5 Attempts to stay within the lines when coloring

1, 2 Rationale: Common developmental norms of the toddler, who is struggling for independence, are an inability to share easily, egotism, egocentrism, and possessiveness. Toddlers have a basic understanding of language and the cognitive ability to follow simple directions. Simple card games are too advanced for toddlers. Enjoying playing with other children and attempting to stay within the lines when coloring are true of preschool-a

Which toys are developmentally appropriate for a 3-month-old infant? Select all that apply. One, some, or all responses may be correct. 1 Push-pull toy 2 Stuffed animal 3 Metallic mirror 4 Colorful mobile 5 Large plastic ball

3, 4 Rationale: A 3-month-old infant is interested in self-recognition and in playing with the baby in the mirror. A colorful mobile will provide visual stimulation for a 3-month-old infant. A 3-month-old infant is too young for a push-pull toy, stuffed animal, or ball.

A nursing instructor asks a student to outline the factors that predispose adolescents to substance use. Which of these statements are correct? Select all that apply. One, some, or all responses may be correct. 1 Substance use makes them more mature. 2 Substance use will improve appetite and sleep disturbances. 3 Using mood-altering substances creates a sense of well-being. 4 Substances will help them cope with worsening performance in school. 5 Substance use will help them achieve increased levels of performance.

1, 3, 5 Rationale: Some adolescents believe that substance abuse makes them more mature. Adolescents often believe that the use of mood-altering substances creates a sense of well-being. Adolescents also believe that substance use will result in an increased level of performance. Hence, all these statements outlined by the student are correct. Appetite and sleep disturbances and a decrease in school performance are warning signs of suicide among adolescents.

Which education would the nurse provide the parents of an infant with pyloric stenosis? 1 It is unlikely that surgery will be necessary. 2 This is a condition with an excellent prognosis. 3 This condition results from an error of metabolism. 4 Special feedings will be needed for a few weeks after surgery.

2 Rationale: In the absence of severe dehydration and malnutrition, the mortality rate is very low; immediate fluid and electrolyte replacement followed by surgery usually results in full recovery. Surgery usually is necessary; the success rate is high, and it produces a rapid recovery. Pyloric stenosis is a structural defect; hypertrophy of the circular muscle of the pylorus causes obstruction at the pyloric sphincter; this is not caused by an inborn error of metabolism. The infant usually resumes regular feedings within 48 hours of surgery.

The nursing instructor asks the nursing student to describe the fine motor skills of a 3-year-old child. Which statement by the student indicates the need for further learning? 1 "A child of 3 years can easily turn doorknobs. 2 "A child of 3 years is able to turn the pages of a book." 3 "A child of 3 years is able to draw simple stick people." 4 "A child of 3 years can skip on alternate feet, jump rope, and skate."

4 Rationale: A child of 5 years is still unable to skip on alternate feet, jump rope, or skate. Hence, when the student says that a toddler of 3 years old can skip on alternate feet, jump rope, and skate, it indicates a need for further teaching. By 3 years, children are able to turn doorknobs and turn the pages of a book one at a time. They are also able to draw simple stick people.

Which describes the similarity between evidence-based practice (EBP) and quality improvement (QI)? 1 Both receive funding from internal sources. 2 Both use data sources from multiple research studies. 3 Both need approval of the Institutional Review Board. 4 Both are conducted by researchers employed for this purpose.

1 Rationale: Both evidence-based practice (EBP) and quality improvement (QI) are funded by internal sources. EBP uses information from multiple research studies; in contrast, QI collects data from client records. EBP does not require the Institutional Review Board approval; QI sometimes may require Institutional Review Board approval. EBP and QI are carried out by practicing nurses and possibly other members of the health care team. Research studies are carried out by researchers.

Which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections? 1 "Wear cotton underwear or lingerie." 2 "Void at least every 6 hours around the clock." 3 "Increase foods containing alkaline ash in the diet." 4 "Wipe the perineum from back to front after toileting."

1 Rationale: Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments. Voiding frequently helps flush ascending microorganisms from the bladder, thereby reducing the risk for urinary tract infections; holding urine for more than 6 hours can lead to urinary tract infections. Foods high in acid, not alkaline ash, help acidify urine; this urine is less likely to support bacterial growth. Alkaline urine promotes bacterial growth. Wiping the genitals from back to front after toileting may transfer bacteria from the perianal area toward the urinary meatus, which will increase the risk for urinary tract infection.

The nurse is obtaining the health history from a 21-year-old client who is seeking contraceptive information. Which factor in the client's history is a contraindication to the use of oral contraceptives? 1 Hypertension 2 A pack-a-day cigarette habit 3 Daily doxycycline taken for acne

1 Rationale: Oral contraceptives may increase blood pressure; they are contraindicated if the client has hypertension. Although clients should be cautioned strongly against smoking, this is not a contraindication if they are younger than 35 years of age. Taking daily doxycycline does not decrease the effectiveness of the oral contraceptive. There is no relationship between oral contraceptives and multiple births.

How is public health nursing different from community health nursing? 1 Public health nursing focuses on a population. 2 Public health nursing focuses on health promotion. 3 Public health nursing is part of a primary health care delivery system. 4 Public health nursing requires nurses to hold a graduate degree.

1 Rationale: Public health nursing focuses on a population or a collection of individuals who have one or more personal or environmental characteristics in common, whereas community health nursing has a primary focus on the health care of individuals, families, and groups in a community. Both public health nursing and community health nursing focus on health promotion. Both types of nursing are part of a community-based health care delivery system and neither is part of primary health care. Both public health nursing and community health nursing require nurses to hold a graduate degree.

Which type of rehabilitation is an essential component to a client's recovery from Guillain-Barré syndrome? 1 Physical therapy 2 Speech exercises 3 Fitting with a vertebral brace 4 Follow-up on cataract progression

1 Rationale: Rehabilitation needs for a client with Guillain-Barré syndrome focuses on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome.

Which education would the nurse provide the parents of a 3-year-old child who has recurrent acute spasmodic laryngitis (spasmodic croup) about why this is a disorder of young children? 1 They have small airways. 2 They are mouth breathers. 3 They have immature immune systems. 4 They are prone to upper respiratory infections.

1 Rationale: Swelling and edema in airways with small diameters lead to the signs and symptoms of croup. Mouth breathing is not the cause of croup. An immature immune system is too general an explanation; it depends on the specific resistance of the individual child. A tendency to contract upper respiratory infections does not explain why only small children get croup.

The nurse documents that a child lacks physical readiness for toilet training. Which assessment finding supports the nurse's conclusion? 1 The child wets 2 diapers per day. 2 The child stays dry for 1 hour during the day. 3 The child behaves impatiently with soiled diapers. 4 The child sits on the toilet for 6 minutes without fussing.

1 Rationale: The child develops voluntary control of the anal and urethral sphincters by the age of 22 to 30 months, allowing the child to remain dry for at least 2 hours. If the child is unable to remain dry for 2 hours, it indicates a lack of physical readiness for toilet training. The number of wet diapers decreases as the child attains physical readiness for toilet training. If a 2-year-old child wets 2 diapers per day, it is a normal finding. If the child becomes impatient with soiled diapers and has the desire to change the diapers immediately, it indicates psychological readiness for toilet training. Sitting on the toilet for 5 to 8 minutes without fussing or getting off also indicates psychological readiness for toilet training.

The nurse is assessing a client admitted with diabetic ketoacidosis. Which statement made by the client indicates a need for further education on sick day management? 1 "I will stop taking my insulin when I am ill because I am not eating." 2 "I will check my urine for ketones when my blood sugar is over 250." 3 "I will alternate drinking Gatorade and water throughout the day while ill." 4 "I will continue all my insulin including my glargine when I am sick."

1 Rationale: The diabetic client's metabolic needs will require the same amount of insulin and sometimes more when in a stressed state, including illness. The client checking the urine for ketones when blood sugar is more than 250, alternating water and Gatorade intake, and continuing insulin indicate that the client has an understanding of the basic sick day rules. Alternating the intake of water and Gatorade throughout the day provides noncarbohydrate water and fluids containing glucose and electrolytes while reducing the risk of consuming too much sugar.

Which topic is most important for the nurse to teach in a community health promotion class for middle-aged adults? 1 Tobacco cessation 2 Infection prevention 3 Alcohol abstinence 4 Pain management

1 Rationale: Tobacco use is a major risk factor for cardiovascular disease, which is the most common cause of death in middle-aged and older adults. In addition, tobacco use is a risk factor for multiple types of cancer, and cancer is the second leading cause of death in middle-aged and older adults. Prevention of infection is also an important topic, but it is not as likely to cause death in this age group as tobacco use. Alcohol abstinence would be an important topic to discuss with groups at risk for alcohol abuse, but abstinence is not recommended for all middle-aged adults. Pain management would be an important topic to discuss with clients who have chronic pain, but it is not the most important topic to teach to all middle-aged adults.

Which concept would the nurse consider when caring for school-aged children who are obese? 1 Enjoyment of specific foods is inherited. 2 There are familial influences on childhood eating habits. 3 Childhood obesity is usually not a predictor of adult obesity. 4 Children with obese parents are destined to become obese themselves.

2 Rationale: Studies have demonstrated that culture and family eating habits have an effect on a child's eating habits. Inheritance is not known to influence eating habits, although it is believed that other hereditary factors are associated with obesity. Childhood obesity is a known predictor of adult obesity. Children with obese parents are not necessarily destined to become obese themselves.

Which assessment question would the nurse ask the parents of a 1-year-old client to assess language development? 1 "Does your child form sentences?" 2 "Does your child say 3 to 5 words?" 3 "Does your child understand 10 words?" 4 "Does your child respond when you say her or his name?"

2 Rationale: The nurse would expect that a 1-year-old client is able to say 3 to 5 words; therefore, this is an appropriate question for the nurse to include when assessing language development. The nurse would not anticipate this client to be able to form sentences. The 1-year-old client should be able to understand up to 100 words, not just 10 words. Asking the parent if the child responds to his or her name is a question used to assess the possibility of hearing impairment versus language development.

In which situation would the nurse consider family members as the primary source of information? Select all that apply. One, some, or all responses may be correct. 1 The client is an older adult. 2 The client is an infant or child. 3 The client is brought in as an emergency. 4 The client is critically ill and disoriented. 5 The client visits the outpatient department.

2, 3, 4 Rationale: The nurse interviews the parents who care for the infant or child. Thus the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The older adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.

Which cause of anemia would the nurse recognize as the most common cause of anemia in 1-year-olds? 1 Thalassemia 2 Lead poisoning 3 Iron deficiency 4 Sickle shape of blood cells

3 Rationale: Breast milk and unfortified infant formulas increase the risk for iron-deficiency anemia in infants. Cow's milk, which is introduced at 1 year of age, is also low in iron and may cause iron-deficiency anemia unless iron supplements or iron-rich solid foods are added to the diet. Thalassemia is a genetic disease that affects specific populations and is not a common disorder. Lead poisoning usually occurs in children older than 1 year, and its prevalence is less than that of iron-deficiency anemia. Sickle cell anemia is a genetic disease that affects specific populations and is not as common as iron-deficiency anemia.

Which goal would the client with dysmenorrhea seeking treatment want to achieve? 1 Reducing the pad saturation rate 2 Making intercourse less uncomfortable 3 Easing the pain of the client's menstruation 4 Eliminating bleeding between menstrual periods

3 Rationale: Dysmenorrhea is painful menstruation; the goal of care is making menstruation less painful. The other options are appropriate for a client who is experiencing excessive menstrual flow (menorrhagia) or dyspareunia (painful intercourse). Bleeding between menstrual periods would require further investigational workup.

In which position would the nurse place the client to obtain an accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 30 degrees 4 Raised to 10 degrees

3 Rationale: Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30 to 45 degrees. Jugular vein distention cannot be assessed accurately if the client is supine, at 90 degrees, or at 10 degrees.

In a child with lead poisoning, where is lead stored while remaining inert? 1 Liver 2 Blood 3 Bones 4 Soft tissues

3 Rationale: Lead is stored in the bones and teeth, where it remains inert. This makes up the largest portion of the body burden, approximately 75% to 90%. Lead does not settle in the liver, blood, or soft tissues. Lead in the body moves via an equilibration process between the blood, the soft tissues and organs, and the bones and teeth.

The nurse documents the data gathered during the assessment in a client's medical record. Which would the nurse do to ensure that the data is meaningful to other health care providers? 1 Record subjective information in own words. 2 Form judgments through written communication. 3 Record objective information using accurate terminology. 4 Compare data from the physical examination with client behavior.

3 Rationale: The nurse would document all objective information using accurate terminology. The nurse would pay attention to the facts and report findings exactly as seen, felt, or smelled. If the information is not specific, another health care provider reading the data gets only general impressions. The nurse would record subjective information in quotations, exactly as described by the client. The nurse would refrain from generalizing or forming judgments during documentation. This information is used to form nursing diagnoses, which must be factual and accurate. During validation, the nurse compares data from the physical examination with client behavior.

A parent asks the nurse what to do when the toddler has temper tantrums. Which play materials would the nurse suggest that the child be offered as another means of expressing anger? 1 Ball and bat 2 Wad of clay 3 Punching bag 4 Pegs and pounding board

4 Rationale: A pounding board with pegs to hammer into holes is a safe toy for toddlers because it is fairly large, easy to manipulate, and sturdy. It also provides an acceptable way for anger to be expressed. The child's motor and hand-eye coordination are too immature for the child to use a ball and bat. A wad of clay is not as effective for releasing anger as a pounding board. A punching bag is appropriate for an older child with more mature motor coordination to compensate for a moving object.

Which education would the nurse provide the family of a preschool-aged child about normal growth patterns? 1 "The rate of physical growth accelerates during this stage of development." 2 "Muscle and bone development are mature during this stage of development." 3 "You can expect your child to keep the potbelly appearance during this stage of development." 4 "Your child's legs will grow in length versus the trunk of the body during this stage of development."

4 Rationale: During the preschool stage of development, the legs will grow in length versus the trunk, as seen during the previous stages of development. The rate of physical growth slows and stabilizes during the preschool stage of development. Muscle and bone development continue to be immature. The potbelly appearance disappears during the preschool stage of development; the preschooler is slender but sturdy, graceful, agile, and posturally erect.

Which intervention is appropriate for the nurse to teach the parents of a child with Duchenne muscular dystrophy? 1 Maintain a high-calorie diet. 2 Institute seizure precautions. 3 Restrict the use of larger muscles. 4 Perform range-of-motion exercises.

4 Rationale: Range-of-motion exercises are essential to help achieve the primary objectives of maintaining optimal muscle function for as long as possible and preventing the development of contractures. A high-calorie diet may result in obesity, which could cause the child to need a wheelchair sooner rather than as late as possible. Seizures are not associated with Duchenne muscular dystrophy. Restricting the use of large muscles could result in disuse atrophy and contractures.

Which developmental skill would the nurse expect a 3-year-old child to be able to do? 1 Hop on one foot. 2 Button a sweater. 3 Cup the hands to catch a ball. 4 Go up stairs while alternating the feet.

4 Rationale: The average 3-year-old child has the physical ability to climb the stairs with alternating feet but may still use both feet on a step to go down the stairs. Cupping the hands to catch an object is an accomplishment of a 5-year-old child. Hopping on one foot is usually not accomplished until a child is 5 years old. A 3-year-old child may be able to self-dress partially, but buttoning is more developmentally appropriate for a 5-year-old.

Which instruction would the nurse give to the parent of a child who has had one episode of diarrhea according to evidence-based practice for this situation? 1 Limit the child's activities, withhold oral feedings, and call the clinic in 4 hours. 2 Wrap the child snugly, offer sugar water, and bring the child to the clinic immediately. 3 Allow the child to continue activities, withhold oral feedings for 24 hours, and call the clinic tomorrow. 4 Continue the child's feedings as usual, observe the frequency of stools, and bring the child to the clinic tomorrow if the diarrhea continues.

4 Rationale: The recommendation for treatment of mild diarrhea is to continue the regular diet. If diarrhea continues for 12 to 24 hours, the child needs to be medically evaluated. Withholding food and fluid puts the child at risk for dehydration, especially if the diarrhea continues; activities are not a factor in the treatment of diarrhea because children self-limit activity when they feel sick. Wrapping the child in a blanket will cause body temperature to increase; sugar water does not include electrolytes and may cause further gastric irritation. This is not an emergency that requires immediate intervention. Although activities are permitted, withholding food and fluid puts the child at risk for dehydration, especially if the diarrhea continues.

Which nursing actions are accurate when measuring a head circumference for an infant? Select all that apply. One, some, or all responses may be correct. 1 Using cloth tape for accuracy 2 Obtaining 1 measurement per visit 3 Documenting the information in the progress notes 4 Using paper tape marked with tenths of a centimeter 5 Placing the tape slightly above the eyebrows and pinna of the ears

4, 5 Rationale: Nursing actions that are accurate when measuring a head circumference for an infant include using paper tape marked in tenths of a centimeter (to facilitate plotting information on growth chart) and placing the tape slightly above the eyebrows and the pinna of the ears (the largest circumference of the head is the target measurement). The use of cloth tape is not recommended because it may stretch, causing an inaccurate measurement; paper or metal tape should be used. The nurse would take several measurements at each visit for accuracy. The head circumference is plotted on the growth chart; the information is not documented in the progress notes.