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 1
Health Promotion and Maintenance
1.
 
What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?a.
 
A cotton ballb.
 
A pen lightc.
 
An opthalmoscoped.
 
A tongue depressor and flashlight
Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated. Options #1, #2, and #3 areinappropriate for these cranial nerves.
2.
 
A client that is involved in a homosexual relationship is scheduled for abdominal surgery. During surgery, the partnerrequests information regarding her status. What would be the appropriate response from the nurse?a.
 
"The physician will be out to inform you after the surgery is complete."b.
 
"I am sorry; I can only give out information to family members."c.
 
"Let me go back and get an update. I will be right back with a report."d.
 
"She is doing fine; just sit back and relax."
It is important to respect client's personal choice of lifestyle. Providing the partner with accurate information is part of being aclient advocate. Option #1 is nurse avoidance. Option #2 is inappropriate. Option #4 is providing false reassurance and is nottherapeutic.
3.
 
As the nurse is making midnight rounds, a geriatric client complains that his feet are cold. Which action would the nurse dofirst?a.
 
Examine the feet for presence of pulses and adequacy of circulation.b.
 
Elevate the foot of the bed and rub the feet to increase circulation.c.
 
Fill a hot water bottle, wrap it in a case, and place on the feet.d.
 
Bring a warm drink to relax and warm the client.
Assessment must be done prior to implementation.The client may have decreased circulation that has increased in severity overthe past few hours. Options #2 and #3 are contraindicated. Option #4 is secondary.
4.
 
The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 on a client who has been on bedrest 48 hours in an unsuccessfulattempt to arrest premature labor at 33 weeks gestation. Based on this result, the nurse would anticipate:a.
 
the administration ofritodrine hydrochloride (Yutopar).b.
 
initiation of an oxytocin (Pitocin) drip.c.
 
delivery of the infant by Cesarean section.d.
 
continuation of bedrest until otherwise indicated.
Since the lungs are adequately mature, there is no need to postpone labor and delivery. Cesarean section is generally preferredfor pre-term infants. Option #1 is no longer necessary as the results indicate sufficient lung maturity for safe delivery. Option #2 isincorrect because the client should either be allowed to progress naturally to a vaginal delivery,,or sectioned
but not induced.Option #4 is no longer necessary with adequately mature lungs.
5.
 
A 14-year-old is first day postoperative after a Harrington Rod placement. Which sign would be most indicative of positiverelief from the pain medication? Client:a.
 
verbalizes pain has decreased.b.
 
refuses more pain medicine.c.
 
is agitated with visitors in the room.d.
 
cooperates with incentive spirometry exercise.
This is the most objective way to quantify the effectiveness of the pain medicine. The nurse can measure breathing. If the client isstill in pain, there will be reluctance to take deep breaths. Options #1 and #2 are not measurable. Option #3 is not measurableand may indicate pain is still present.
6.
 
A female client is diagnosed with human papillomavirus (HPV). Which client statement illustrates an understanding of thepossible sequelae of this illness? "I will:a.
 
take all of the antibiotics until they are finished."b.
 
use only prescribed douches to avoid a recurrence."c.
 
return for a pap smear in 6 months."d.
 
avoid using tampons for 8 weeks."
Several strains of the human papillomavirus (HPV) are associated with cervical cancer. Option #1 is incorrect because antibioticsare not used for viral infections. Option #2 is incorrect because douches will not prevent recurrence. Option #4 is incorrectbecause tampons do not contribute to the problem as in toxic shock syndrome.
7.
 
Which observations would indicate a complication of smoking while using oral contraceptives?a.
 
Weaknessb.
 
Irritabilityc.
 
Chest paind.
 
Abdominal cramping
Smoking in conjunction with oral contraceptives greatly increases a woman's risk of coronary artery disease. Options #1, #2, and#4 may occur, but are not as likely as Option #3.
 
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8.
 
A geriatric client, newly diagnosed with diabetes, is being discharged. She is alert, oriented and able to independentlymaintain her activities of daily living. Treatment will consist of a 1500-caloric diabetic diet, insulin, and regular exercise bywalking 30 minutes a day. What is a priority concern at the time the client is discharged?a.
 
Does the client have adequate vision and manual dexterity to administer her own insulin?b.
 
Does the client understand the impact diabetes will have on her lifestyle?c.
 
Since the client is living alone, does she need Home Health Care to check on her daily?d.
 
Does the client understand how to perform her daily urinary sugar and acetone determinations?
It is very important that the geriatric client have the visual and manual skills to administer their insulin. Options #2 and #3 areimportant to determine; but Option #1 is a priority. Urinary tests are not commonly used to monitor diabetics
.9.
 
The family members of an 85-year-old think their father is masturbating. Which response by the nurse would be best?a.
 
"I understand your concern because this is not a normal part of aging."b.
 
"I would not worry about this behavior. He will stop soon."c.
 
"This is considered a normal behavior."d.
 
"The best thing you can do is talk to your father about this behavior."
Masturbation is an activity that some elderly engage in. Options #1 and #2 are inappropriate. Option #4 might embarrass thefather and may cause feelings of guilt and anxiety.
10.
 
The parents of a child who has just been diagnosed with a chronic illness are concerned about the sibling's sudden changein behavior. Which response by the nurse would be best? "Her brother is:a.
 
feeling left out right now, but we plan to include him in his sister's care."b.
 
feeling left out right now but will start acting normal soon."c.
 
worried about her and is just reacting to his fear."d.
 
going through a normal developmental stage."
Total family participation is encouraged when the sibling is included. Options #2 and #3 may be appropriate but do not help thefamily adjust. Option #4 is incorrect since the sibling is reacting to his sister's illness.
11.
 
A mother tells you that the 7-year-old sibling of a child with cystic fibrosis is having difficulty in school, fights frequently withplaymates and throws his toys. Which response by the nurse would be best?a.
 
"Did he have these behaviors before his sister was diagnosed?"b.
 
"That is typical of 7-year-olds."c.
 
"Spend time with each child daily, and it will stop."d.
 
"He is jealous of the attention his sister is receiving."
Obtain information about his behavior before the diagnosis to be able to assess a cause for the disruptive behavior. Option #2 isnot accurate. Options #3 and #4 may be correct. However, the nurse must assess behavior prior to his sibling's illness.
12.
 
During a discussion with the nurse, parents share their feelings of frustration with their 14-year-old who refuses to wear aback brace after surgery for scoliosis. The nurse's best response would be that the teenager is probably concerned with:a.
 
her image.b.
 
being separated from her peersc.
 
loss of control.d.
 
physical discomfort.
Adolescents have a concern with their image. Erikson has identified this state as "Identity versus Role Diffusion." Option #2 is aconcern of this stage, but is not appropriate for what the question is asking. Option #3 is more appropriate for a school-age child.Option #4 is incorrect for this situation.
13.
 
A pelvic exam is planned on a 15-year-old client with sharp bilateral pelvic pain. Which nursing action would be mostappropriate?a.
 
Request removal of all clothing.b.
 
Collect a urine and fecal specimen.c.
 
Give a brief explanation of the procedure.d.
 
Begin health teaching related to sexually-transmitted diseases.
Preparation of client is important for all procedures, especially in this case. A pelvic exam can be extremely embarrassing for a 15-year-old. Options #1, #2, and #4 are appropriate after explanation and client preparation, or after the procedure is completed.
14.
 
A hypertensive client returns to the clinic for reevaluation of his medication. His blood pressure is 180/100. The nursequestions the client regarding how he is taking his medication. What response by the client indicates that he understandsand has been taking the medication as prescribed?a.
 
"I take my medication every morning. If my blood pressure is high, I take another dose in the evening."b.
 
"I take my medication every day at the same time regardless of how I feel. I have not missed any doses."c.
 
"I take my medication every day and make sure that I drink a large amount of liquid each time I take it."d.
 
"If I have a headache, I don't take my medication. If I miss the morning dose, then I take two pills in the evening."
This option best describes how the client should take the medication for hypertension. It is important that he take it every day.However, it may be a problem if he is consuming a large amount of water during the day. If he is taking the medication correctly,he needs to have the medication reevaluated since his blood pressure remains high.
 
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15.
 
An 8-lb., 6-oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonatebecomes jittery and lethargic?a.
 
Administer insulin.b.
 
Administer oxygenc.
 
Feed the infant glucose water (10%).d.
 
Place infant in a warmer.
After birth, the infant of a diabetic mother is often hypoglycemic. Option #1 would maximize the problem. Option #2 would beused if the neonate was hypoxic. Option #4 is a routine nursing action for all newborns.
16.
 
A 17-year-old is beginning chemotherapy for her malignancy. Which statement indicates she has a realistic perception of her health status?a.
 
"I will be cured after my therapy is completed."b.
 
"I may need to get a wig during my chemotherapy."c.
 
"I will be able to continue my current school schedule."d.
 
"I must have done something to cause this illness."
This statement reflects the client's understanding of the side effects of chemotherapy. Option #1 may or may not occur. Option#3 is not realistic. It may be possible at times, but the question requests a "realistic perception." Option #4 is inaccurate and mayreflect blame and guilt.
17.
 
A 21-year-old female has just been told by the physician that her biopsy results indicate breast cancer. What would be themost appropriate next action for tne nurse to take?a.
 
Ask the client if she has any questions.b.
 
Encourage client to talk about her feelingsc.
 
Leave client alone for awhile.d.
 
Call the chaplain for the client.
Encouraging the client to talk about feelings allows the client to cry or express her reaction. Options #1, #3, and #4 do not allowfor immediate expression of reaction to this crisis
.18.
 
A female client reports that for the last 4 months a lump in her right breast has been growing larger. The nurse shouldrecommend the client take which action?a.
 
Notify her physician to schedule a mammogram.b.
 
Begin taking large doses of vitamins.c.
 
Limit sodium intake.d.
 
Immediately stop any hormone treatment
A mammogram is an x-ray of the breast. It usually shows the presence of a lesion if one is present. Positive zero radiography (typeof mammogram) has the ability to detect carcinomas 1 to 2 years prior to formation of a palpable 1 cm. lesion. Option #2 isincorrect ^ because specific vitamin therapy may be useful in some cases. It is not curative alone. Option #3 is incorrect becausesodium has not been associated with breast cancer. Option #4 is incorrect because hormones have not been known to causebreast cancer.
19.
 
The nurse is preparing a 40-year-old client for diagnostic tests to determine if she has a malignancy in her reproductivesystem. The client is having difficulty concentrating, appears tense, and is wringing her hands constantly. Which responseshould the nurse make?a.
 
"You seem to be anxious about the tests. Tell me what you are thinking about."b.
 
"You need to pay more attention to what I'm saying. You'll be less anxious if you understand these tests."c.
 
"Why are you so restless? Your physician is very good."d.
 
"I know you're worried about these tests, but I'm sure everything will be fine."
This response acknowledges the client's concerns and allows exploration other fears. Options #2, #3, and #4 provide falsereassurance and do not allow the client an opportunity to express and deal with her feelings.
20.
 
The nurse assesses a prolonged late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV tostimulate labor. The priority nursing intervention would be to:a.
 
turn off the infusion.b.
 
turn client to left.c.
 
change the fluids to Ringer's Lactate.d.
 
increase mainline IV rate.
Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration. Option #2 may help the deceleration, but it is not priority. Options #3 and #4 will have no influence
.21.
 
When providing physical care for a client over 65-years-old, which is the most reliable sign of an infection?a.
 
Feverb.
 
Hypotensionc.
 
Leukocytosisd.
 
Tachypnea
Tachycardia and tachypnea may be the only signs of an infection. A sudden onset of confusion may also be a sign. Option #1,fever, may be absent in 25% to 30% of clients. Option #2, hypotension, is incorrect. Option #3, over 20% of elderly clients with aninfection may present without leukocytosis.
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