Nursing questions module 1 best exam solutions tested and verified solutions with A+ grad, Exams of Nursing

Download Nursing questions module 1 best exam solutions tested and verified solutions with A+ grad and more Exams Nursing in PDF only on Docsity!

Nursing questions module 1 best exam solutions

tested and verified solutions with A+ grade

1.A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson’s theory of psychosocial development. According to Erikson’s theory, which of the following tasks represents the primary developmental task of this child? Mastering useful skills and tools Rationale: According to Erikson’s theory of psychosocial development, the school- age child’s task is to master useful skills and tools of the culture (industry versus inferiority). Gaining independence from parents is the psychosocial task of the adolescent. Developing a sense of trust in the world is the psychosocial task of an infant. Developing a sense of control over self and body functions is the psychosocial task of the toddler. 2.A nurse is assessing a newborn infant for jaundice. Which of the following actions should the nurse take to assess the infant for its presence? Apply pressure with a finger on the infant's forehead Rationale: To assess an infant for jaundice, pressure is applied with a finger over a bony area such as the nose, forehead, or sternum for several seconds to empty all capillaries in that spot. If jaundice is present, the blanched area will appear yellow before the capillaries refill. Jaundice is first noticeable in the head and then progresses gradually toward the abdomen and extremities because of the newborn infant’s circulatory pattern. Squeezing the infant’s nail beds and brachial area and applying pressure with a finger over the umbilical area are all incorrect methods of assessing for jaundice. Assessing for jaundice in natural light is recommended because artificial lighting and reflection from nursery walls may distort the actual skin color. Visual assessment of jaundice does not, however, provide an accurate assessment of the level of serum bilirubin. 3.A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. The nurse should: Document the findings Rationale: The normal fetal heart depends on gestational age (usually higher in the first trimester) and is generally in the range of 120 to 160 beats per minute. A FHR of 160 beats per minute is within the normal range, so documentation is the only action

indicated. 4.A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. The nurse tells the mother: To secure the infant in the middle of the back seat in a rear-facing infant safety seat If a passenger-side air bag is deployed, the air bag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car. 5.An older female client asks a nurse why her hair has turned gray. Which of the following responses is most appropriate for the nurse to make to the client? "A loss of melanin occurs in the normal aging process." Rationale: The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from ultraviolet rays, paler skin color, and graying hair. Although the skin becomes thinner with the aging process and the number of sweat glands and blood vessels decreases, these changes are unrelated to graying hair. Heredity factors influence when the process of graying begins but do not cause the graying of hair.

6. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse determines that: Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth Rationale: A hepatitis B screen is performed to determine the presence of antigens in maternal blood. If they are present, the newborn will need to receive hepatitis immune globulin and vaccine soon after birth. Therefore, noting that the results are negative, noting that the client needs to receive the hepatitis B series of vaccines, and noting that the results indicate that the mother does not have hepatitis B are all incorrect interpretations.

7.A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate? Applying an ice pack to the perineum Rationale: Ice causes vasoconstriction and is most effective if applied to the perineal area soon after birth to prevent edema and numb the area. Ice is used for the first 12 to 24 hours after a vaginal birth. Sitz baths, which provide continuous circulation of water, cleanse and comfort the traumatized perineum. Warm water is most effective after 24 hours have elapsed since delivery. An IV opioid analgesic is not necessary. Rather, an anesthetic spray that will decrease surface discomfort may be used. It is not necessary to notify the nurse-midwife or physician. 8.A nurse is determining the estimated date of delivery for a pregnant client, using Nagele's rule, and notes documentation that the date of the client's last menstrual period was August 30, 2013. The nurse determines the estimated date of delivery to be: June 6, 2014 Rationale: Nagele’s rule is often used to establish the estimated date of delivery. This method involves subtracting 3 months and adding 7 days to the date of the first day of the last normal menstrual period, then correcting the year. Subtracting 3 months from August 30, 2013, brings the date to May 30, 2013; adding 7 days brings it to June 6,

2013. Finally, the year is corrected, bringing the estimated date of delivery to June 6,

9.A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant: At the level of the nipples Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head’s circumference. The average circumference of the chest is 30.5 to 33 cm (12 to 13 inches). (If molding of the head is present, the head and chest measurements may be equal at birth.) The other options are incorrect anatomical areas for measuring chest circumference. 10 A nurse reviews the health history of a client who will be seeing the physician to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which of the

following findings in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? The client has been treated for breast cancer. Rationale: Combination oral contraceptives contain both estrogen and progestin and are contraindicated during pregnancy and for women who have (or have a history of) the following disorders: thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary-artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They are used with caution in women with diabetes mellitus, women who smoke heavily, women with risk factors for cardiovascular disease (hypertension, obesity, hyperlipidemia), and women anticipating elective surgery in which thrombosis might be expected. 11.A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which of the following toys are most appropriate for these activities? Blocks and push-pull toys Rationale: Toys for the toddler should meet the child’s needs for activity and inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger paints, and bubbles; push-pull toys; large balls; sand and water play; blocks; painting; coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board games, videos, and cutting-and-pasting toys are more appropriate play activities for the preschooler. 12.The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in a: Booster seat with one of the car’s seat belts placed over the child Rationale: A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child’s chest and pelvis. The child should not be placed in the front seat. A car safety seat is used for the child who weighs less than 40 lb. These seats are placed in the middle of the back seat in a rear-facing position.

13.A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse tells the client that: The test will need to be repeated during the pregnancy Rationale: A client is not immune to rubella if the titer is 1:8 or less. If the client is not immune, retesting will be performed during the pregnancy. Additionally, rubella immunization is required after delivery if the client is not immune. Therefore telling the client that she has developed immunity to the rubella virus, telling her that she may have been exposed to rubella, and telling her that the test results are normal are all incorrect. 14.A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. The nurse should tell the mother: That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity Rationale: Sex play and masturbation are common among toddlers. Parents should respect the toddler’s curiosity as normal without judging the toddler as bad. Parents who discover children involved in sex play may casually tell them to dress and direct them to another play activity, thereby limiting sex play without producing feelings of shame or anxiety. Bringing the children to a child psychologist, separating them at play, and punishing them are all inappropriate. 15.The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? "I need to be sure to drink adequate fluids with my meals." Rationale: To alleviate nausea and vomiting, the client should avoid drinking fluids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage.

16.A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? Blowing repeatedly in short puffs Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. The woman would not be encouraged to hold her breath or perform the Valsalva maneuver, which is a bearing-down maneuver. 17.A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is: Gravida 6, para 2 Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Therefore this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). Pregnancy outcomes may also be described with the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). The GTPAL for this client would be G = 6, T = 1, P = 1, A = 3, L = 2. 18.A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? Headache Rationale: The adverse effects associated with a subarachnoid block include maternal hypotension, bladder distention, and postdural headache. Postdural headache occurs as a result of cerebrospinal fluid leakage at the site of dural puncture. A spinal

283573326 headache is postural, worsening when the woman is upright and possibly disappearing when she is lying flat. Bed rest with oral or intravenous hydration helps relieve the headache. Nausea, vomiting, and pruritus are adverse effects associated with the use of intrathecal opioids. 19.Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus? Midway between the symphysis pubis and umbilicus Rationale: Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus may be palpated midway between the symphysis pubis and the umbilicus but then rises to a level just above the umbilicus and then sinks to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus begins to descend by approximately 1 cm, or one finger’s breadth, per day. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. 20.A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take on the basis of this finding? Document the findings Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore the nurse would most appropriately document the findings. Checking the client’s temperature, reporting the findings to the nurse- midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife. 21 A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? The infant says "Mama."

283573347 283574794 Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age. 22.A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). The nurse tells the adolescent that: Use of a latex condom can prevent transmission of STIs Rationale: Use of a condom during intercourse can prevent transmission of STIs. Abstinence is not the only way to prevent transmission of an STI. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs. 23.A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? Gently stimulate the infant by rubbing his back while administering oxygen Rationale: The Apgar score is a method of rapid evaluation of an infant’s cardiorespiratory adaptation after birth. The nurse scores the infant at 1 minute and 5 minutes in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color. The infant is assigned a score of 0 to 2 in each of the five areas, and the scores are totaled. If the score ranges from 8 to 10, no action is needed other than support of the infant’s spontaneous efforts and continued observation. If the score falls between 4 and 7, the nurse gently stimulates the infant by rubbing his back while administering oxygen. The nurse also determines whether the mother received opioids, which may have depressed the infant’s respirations. If the score is between 1 and 3, the infant needs resuscitation. 24A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, the nurse ensures that: A female physician examines the woman Rationale: Fear, modesty, and a desire to avoid examination by men may keep some

women from seeking health care during pregnancy. In many cultures (e.g., Muslim, Hindu, Latino), exposure of a woman’s genitals to men is considered demeaning. Nurses must remember that the reputations of women from these cultures depend on their demonstrated modesty. It is best for a female physician or practitioner to perform the examination. If this is not possible, the woman should be carefully draped, with her legs completely covered. A female nurse should remain with the woman at all times. Obtaining permission from the husband may be necessary before an examination or treatment can be performed. 25.A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? Doppler transducer Rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds. 26A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant’s being brought into the home. Which of the following statements is the most appropriate response for the nurse to make to the client? "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." Rationale: Sibling adaptation to the birth of an infant depends largely on age and developmental level. Very young children (2 years or younger) are unaware of the maternal changes occurring during pregnancy and are unable to understand that a new brother or sister is going to be born. Even though toddlers have little perception of time, if any changes in sleeping arrangements need to be made they should be carried out several weeks before the birth of the new baby. Until a child feels secure in the affection of his or her parents, expecting a 2-year-old to welcome a new "stranger" is unrealistic. The parents can be taught to accept strong feelings such as anger, jealousy, and frustration without judgment and to continue to reinforce the child’s feelings of being loved.

27.A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which of the following findings is noted on the electronic monitoring recording strip? Absence of accelerations after fetal movement Rationale: In a nonreactive (nonreassuring) stress test, the monitor recording would not demonstrate the required characteristics of a reactive (reassuring) recording within a 40-minute period. In a reactive (reassuring) recording, at least two fetal heart accelerations, with or without fetal movement detected by the woman, occur within a 20-minute period, peak at least 15 beats per minute above the baseline, and last 15 seconds from baseline to baseline. 28The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse tells the mother that: Body piercing is generally harmless as long as it is performed under sterile conditions Rationale: Generally body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some of the complications that may occur are bleeding, infection, keloid formation, and the development of allergies to metal. The area needs to be cleaned at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not associated with body piercing; however, they are a possibility with tattooing. 29.A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client's record and interprets this sign as indicating: That the cervix was seen to be violet Rationale: One probable sign of pregnancy is the Chadwick sign — violet coloration of the cervix, which is normally pink. The color change, which also extends into the vagina and labia, occurs because of increased vascularity of the pelvic organs. Thinning of the cervix is termed the Hegar sign, and softening of the cervix is called the Goodell sign. These are both probable signs of pregnancy.

30A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which of the following findings is noted? The toes flare and the big toe is dorsiflexed. Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited. 31.A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant: Overarticulates words Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker’s face and lips. The nurse would watch to see that the nursing assistant avoided situations in which there is a glare or shadows on the client’s field of vision. The nurse would also remind the assistant to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The assistant should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues. 32A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult because such clients: Ignore physical symptoms and postpone seeking health care Rationale: Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help the

nurse and client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and other chronic diseases. Young adults are not at risk for serious illness. The young adult may or may not be exposed to hazardous substances and may or may not be able to afford health insurance. 33.A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which of the following actions should the nurse include in the plan? Encouraging bedtime reading or listening to music Rationale: Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading or listening to music. The use of a night light will foster an environment that is both helpful and safe. 34A nurse is reviewing the medical notes of a client seen by the physician to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which of the following findings is documented? Palpable fetal movement Rationale: The positive indicators of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus with sonography. Amenorrhea is a presumptive sign of pregnancy because it is experienced and reported by the woman. Presumptive signs are not reliable indicators of pregnancy, because any may be caused by conditions other than pregnancy. Thinning of the cervix (the Hegar sign) and a positive pregnancy test result are probable indicators of pregnancy. A false-positive pregnancy test result may occur as a result of an error in reading, the presence of protein or blood in the urine, a recent pregnancy, a recent first-trimester abortion, or medications the client is taking. 35.Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? Vastus lateralis muscle Rationale: Vitamin K is administered to the newborn infant in the hour after birth to help prevent hemorrhagic disease. The best site for intramuscular injection is the infant’s vastus lateralis muscle, although, if necessary, the rectus femoris muscle may

be used. The large vastus lateralis muscle is located away from the sciatic nerve, as well as the femoral artery and vein. The rectus femoris muscle is nearer these structures, and an injection there is more hazardous. The deltoid muscle is not used to administer intramuscular injections in the newborn infant. The gluteal muscles are never used until a child has been walking for at least a year. These muscles are poorly developed and dangerously near the sciatic nerve. 36.A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. On the basis of this finding, which action by the nurse is most appropriate? Documenting the finding Rationale: After delivery, bradycardia (pulse rate 50 to 70 beats per minute) may occur. The lower pulse rate reflects the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume and permits a slower heart rate to provide adequate maternal circulation. It is not necessary to notify the nurse-midwife or physician immediately, because a pulse rate of 55 beats per minute is a normal finding. The client should remain on bed rest in the immediate postpartum period. Although range-of-motion exercises are important for the client on bed rest, this action is unrelated to the data in the question. Therefore, the most appropriate nursing action is to document the finding. 37.A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first? Stopping the oxytocin infusion Rationale: Oxytocin stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of uterine contractions. The nurse monitors the client who is receiving oxytocin closely and, if uterine hypertonicity or a nonreassuring FHR pattern, such as late decelerations occurs, intervenes to reduce uterine activity and increase fetal oxygenation. The nurse would first stop the oxytocin infusion. The nurse would next increase the IV rate of the nonadditive solution, place the woman in a side-lying position, and administer oxygen through a snug face mask at a rate of 8 to 10 L/min. The nurse would then notify the nurse- midwife or physician of the adverse reaction, the nursing interventions taken, and the response to interventions. The nurse would monitor the woman’s vital signs while she

is receiving oxytocin, but this would not be the first action in this situation. 38The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should tell the parents: That this is normal behavior for an adolescent Rationale: Identity formation is the major developmental task of adolescence. Energy is focused within the self, and the adolescent is sometimes described as egocentric or self-absorbed. Frustrated parents often describe teenagers during this phase as self- centered, lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on himself or herself, and determine who he or she is going to be. Erikson describes the conflict of this phase of psychosocial development as identity formation versus role confusion. The assertions that a psychologist is needed and that the behavior is the result of spoiling are incorrect. Restriction of social privileges will cause resentment and rebellion in the adolescent. 39.According to Erik Erikson’s developmental theory, which of the following choices are developmental tasks of the middle adult? Providing guidance during interactions with his children Rationale: According to Erikson’s developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Making decisions concerning career, marriage, and parenthood; redefining self-perception and capacity for intimacy; and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult. 40.A nurse is performing an admission assessment on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. The nurse's next action should be to: Ask the client about medications he is taking Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of

chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. Although the nurse may report the client’s concern and document the concern in his medical record, the next action is to ask the client about the medications he is taking. 41.A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? 16 weeks Rationale: Fetal movements (quickening) are first noticed by the multigravida pregnant woman at 16 to 20 weeks of gestation and gradually increase in frequency and strength. The other options are incorrect. 42.A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse tells the client that: Devices that apply pressure alone are available over the counter Rationale: As a complementary alternative therapy, acupressure over the Neiguan acupuncture point (approximately three fingers’ width above the wrist crease on the inner arm) is performed with the use of electrical impulses or with a device that applies pressure alone. Devices that apply an electrical impulse over this point require a prescription from a physician or nurse-midwife. Devices that apply pressure alone are available over the counter. Certain types (those that are noninvasive and are not harmful) may be acceptable for use during pregnancy. Not all types of complementary alternative therapies can be used during pregnancy, because some may be harmful to the mother, fetus, or both. 43A nurse is assisting a nurse-midwife in performing an amniotomy. After the procedure, the nurse should perform the following actions. Assign the correct order of priority to the items on the list, using 1 to indicate the first action and 5 the last. The correct order is: Assess the fetal heart rate Assess the color, odor, and other characteristics of the amniotic fluid Check the woman's heart rate and blood pressure

Assist the woman in cleaning the perineal area Ask the woman about the need to void Rationale: The FHR is assessed immediately after amniotomy. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through it. Next the nurse checks the amniotic fluid for abnormalities, which could indicate a problem with the fetus. The nurse should then assess the mother’s vital signs to ensure that they have not been affected by the procedure. The nurse then assists the woman in cleaning the perineal area and finally asks the woman about the need to void. 44.A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question does the nurse ask? "Do you smoke cigarettes?" Rationale: Oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke. The risk of thromboembolitic phenomena is increased in the presence of other risk factors, especially heavy smoking and a history of thrombosis. Additional risk factors include hypertension, cerebrovascular disease, coronary artery disease, and surgery in which postoperative thrombosis might be expected. Dieting, menstrual cramping, and strenuous exercise are not risk factors associated with the use of oral contraceptives. 46.A nurse is discussing birth control methods with a client who is trying to decide which method to use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus? Personal Rationale: Personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method. The nurse should educate the client about the various contraceptive methods available so that expressions of preference may be based on understanding. The desire to have children in the future, work and home schedules, and family planning goals may affect the choice of birth control method but are not motivating factors.

47A female client asks a nurse about the advantages of using a female condom. The nurse tells the client that one advantage is: That it offers protection against sexually transmitted infections (STIs) Rationale: A female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. The condom, which is prelubricated, is available without a prescription. It cannot be combined with a male condom and should be used just once, then discarded. Like the male condom, the female condom provides protection against STIs. The pregnancy failure rate with typical use is approximately 21%. 48.The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse tells the mother: That the crust is to be expected as a normal part of healing Rationale: After circumcision, a yellow crust may form over the circumcision site. This crust is a normal part of healing and should not be removed. The mother should be told to expect this occurrence. Yellow crusting or discharge is not a sign of infection, and the pediatrician does not need to be notified, because the finding is to be expected. 49.A nurse is assessing language development in a toddler from a bilingual family. The nurse expects that the child’s language development: Is slower than expected Rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. A child from a bilingual family does not require assistance from a speech therapist to ensure language development. 50.A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse

provides information to the client about the procedure. The nurse tells the client that: That she may need to drink fluids before the test and may not void until the test has been completed Rationale: For a transabdominal ultrasound, the woman is positioned on her back, with her head elevated, but is turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure takes 10 to 30 minutes. For transvaginal ultrasonography, a transvaginal probe is inserted into the vagina. 51.A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client's ability to maintain a patent airway because the normal aging process: Decreases an older client's ability to clear secretions Rationale: Respiratory changes related to the normal aging process decrease an older adult’s ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished. 52.A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. On the basis of these findings, what is the most appropriate nursing action? Notify the nurse-midwife of the findings Rationale: The woman’s temperature should range from 98° F to 99.6° F. The pulse rate should be 60 to 90 beats per minute, and respirations should be 12 to 20 breaths

per minute. A temperature of 100.4° F or higher, especially in the presence of an increased pulse rate and faster respirations, suggests infection, and the nurse-midwife or physician should be notified. Although the findings would be documented, the nurse would most appropriately contact the nurse-midwife or physician. Once the nurse has contacted the nurse-midwife or physician, the nurse would continue the assessment. Vital signs would be rechecked as prescribed or in accordance with agency protocol. 53.A nurse monitoring a client in labor notes this fetal heart rate pattern (see figure) on the electronic fetal monitoring strip. The most appropriate nursing action would be to: Continue to monitor the client and fetal heart rate patterns Rationale: Early decelerations are not associated with fetal compromise and require no intervention. They occur during contractions as the fetal head presses against the woman’s pelvis or soft tissues, such as the cervix. Early decelerations have a gradual rather than an abrupt decrease from baseline. They have a consistent appearance in that one early deceleration looks similar to others. Early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point of the deceleration occurring near the contraction’s peak. The rate at the lowest point of the deceleration usually remains greater than 100 beats per minute. 54.A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. On the basis of this finding, what is the most appropriate action for the nurse to take? Documenting the findings Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths per minute (average 40). The nurse would document the findings. Contacting the pediatrician, placing the infant in an oxygen tent, and wrapping an extra blanket around the infant are all unnecessary actions. 55.A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing: A sense of industry Rationale: According to Erikson, the central task of the school-age years is the

development of a sense of industry. The school-age child replaces fantasy play with "work" at school, crafts, chores, hobbies, and athletics. Development of trust is the task of infancy. Development of autonomy is the task of toddlerhood. Development of initiative is the task of the preschooler. 56.A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client? Aunts, uncles, grandparents, and cousins Rationale: The extended family includes relatives, (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of husband and wife and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint living situation. 57A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse tells the mother: That this is normal for breastfed infants Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools. Formula- fed infants excrete stools that are more solid and pale yellow to light brown. Decreasing the number of feedings might be harmful to the newborn. Because this finding is an expected occurrence in a breastfed infant, infection is not a concern. 58Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and tells the couple that: Multiple births occur in a small percentage of clomiphene-facilitated pregnancies Rationale: Multiple births (usually twins) occur in a small percentage (8% to 10%) of clomiphene-facilitated pregnancies, and the couple should be informed of this. The medication is available in 50-mg tablets for oral use. There is no available intravenous form. Breast engorgement is a common side effect of the medication that

reverses after medication withdrawal. When ovulation does occur as a result of use of clomiphene, it is usually within 5 to 10 days after the last dose. The couple is instructed to engage in coitus at least every other day during this time. 59The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. The nurse instructs the mother to: Give the infant cool liquids or a Popsicle and hard foods such as dry toast Rationale: Although sometimes asymptomatic, teething is often signaled by behavior such as nighttime awakening, daytime restlessness, an increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health-care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the healthcare provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child’s age, can relieve discomfort. 60.A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. On the basis of this finding, which priority action should the nurse take? Checking the client's uterine fundus Rationale: During the fourth stage of labor, the woman’s vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure decreases as the blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is that the uterus is not firmly contracting and compressing open vessels at the placental site. Therefore the nurse should check the client’s uterine fundus for firmness, height, and positioning. Notifying the nurse-midwife immediately is not necessary unless the nurse is unable to determine the cause of bleeding and is unable to correct it. Continuing to check the client’s vital signs every 15 minutes will delay necessary intervention. Although the findings will need to be

documented, the priority action is to assess the client for bleeding. 61A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. The nurse interprets this finding as: A reassuring Rationale: When assessing the FHR, the nurse determines that the findings are reassuring or whether further steps should be taken to clarify data or correct problems. Reassuring signs include an average rate between 120 and 160 beats per minute at term; a regular rhythm or a rhythm with slight fluctuations; accelerations from the baseline rate, often occurring with fetal movement; and the absence of decreases from the baseline rate. A nonreassuring sign suggests fetal distress, warranting immediate intervention and indicating the need to contact the physician. 62.A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? "Egg white should not be given to my infant because of the risk for an allergy." Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant’s intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant’s intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the pediatrician’s preference, fruits and vegetables may be introduced first. 63.A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. On the basis of this result, which action should the nurse take first? Contact the nurse-midwife or physician Rationale: The blood glucose level for a newborn infant should remain above 40 mg/dL. If glucose is not constantly available to the brain, permanent damage may

283573734 283573742 occur. The nurse would most appropriately contact the nurse-midwife or physician to obtain prescriptions regarding feeding the infant with a low blood glucose. The nurse would also follow agency policy regarding feeding infants with a low blood glucose level if such a policy exists. A common practice is to feed the infant if the glucose level is 40 mg/dL or less. Holding the next scheduled feeding is harmful. Although the nurse would document the laboratory result, this is not the most appropriate initial action. Another blood sample may need to be drawn if it is prescribed, but asking the laboratory to repeat the test in 2 hours is not the appropriate action. 64.A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. On the basis of this finding, the nurse should: Document these measurements in the infant's health-care record Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant’s head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect. 65.A nurse is assessing the motor development of a 24-month-old child. Which of the following activities would the nurse expect the mother to report that the child can perform? Select all that apply. Align two or more blocks Turn the pages of a book one at a time Rationale: By 24 months of age, the toddler can put on simple items of clothing but cannot differentiate front and back. Some other activities that children at this age can perform include zipping large zippers, putting on shoes, washing and drying their hands, aligning two or more blocks, and turning the pages of a book one at a time. The fine motor skill needed to tie shoes is not yet developed. By the age of 4 to 5 years, the child is more independent and can dress, eat, and go to the bathroom without help. 66.A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information?

"Frequent urination and burning when I urinate are expected." Rationale: The new mother is instructed to notify the nurse-midwife or physician if any of the following occurs: fever; localized areas of redness, swelling, or pain in either breast that is not relieved by support or analgesics; persistent abdominal tenderness; feelings of pelvic fullness or pressure; persistent perineal pain; frequency, urgency, or burning on urination; a change in the character of lochia (increased amount, resumption of bright-red color, passage of clots, foul odor); localized tenderness, redness, swelling, or warmth of the legs; and swelling, redness, drainage from, or separation of an abdominal incision. 67.A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should: Keep hospital routines as similar as possible to those at home Rationale: The nurse can decrease the stress of hospitalization for the toddler by incorporating the toddler’s usual rituals and routines from home into nursing care activities. Keeping hospital routines as similar to those of home as possible and recognizing ritualistic needs gives the toddler some sense of control and security and eases feelings of helplessness and fear. Spending as much time as possible with the toddler and allowing the toddler to play with other children and select the toys he would like to play with may be appropriate interventions, but keeping the hospital routine as similar as possible to the routine at home will best maintain the toddler’s sense of control and security and ease feelings of helplessness and fear. 68.A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to: Use water and a cotton swab and rub the teeth Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting

excessive amounts of fluoride. Dipping the infant’s pacifier in maple syrup is unacceptable because of the risk of tooth decay. 69.A nurse is conducting a psychosocial assessment of a young adult. Which of the following observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. The young adult verbalizes satisfaction with friendships. The young adult has a sense of meaning and direction in life. Rationale: Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Signs of emotional health in the young adult include a sense of meaning and direction in life, successful negotiation of transitions, absence of feelings of being cheated or disappointed by life, attainment of several long-term goals, satisfaction with personal growth and development, reciprocated feelings of love for a partner, satisfaction with social interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and no unrealistic fears. 70.A home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications? The client's mother Rationale: African-American families are oriented around women. Within the African-American family structure, the wife/mother is often charged with the responsibility of protecting the health of family members. The African-American woman is expected to assist each family member in maintaining good health and in determining the course of treatment if a family member becomes ill. The nurse must recognize the importance of the African-American woman in disseminating information and in assisting the client in making decisions. Although the African- American man may be included in the decision-making process, the African- American family is often matrifocal, so the nurse ensures that the woman is present. Therefore the other options are incorrect. 71A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip