The nurse teaching an obese client about nutritional needs and weight loss should include all of the following except __________.
Answer : D
Explanation:
Start a fast weight-loss diet.
An assessment of the skull of a normal 10-monthold baby should identify which of the following?
Answer : A
Explanation:
The posterior fontanel should close by the age of 2 months.
Which is the best way to position a client"™s neck for palpation of the thyroid?
Answer : A
Explanation:
Flexed toward the side being examined.
A client, age 28, is 8 -
â„
months pregnant.
She is most likely to display which normal skin-color variation?
Answer : D
Explanation:
Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes.
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus.
Which of the following nursing actions should be included in the client"™s care plan?
Answer : A
Explanation:
If a woman is sensitized to the Rh factor, it poses a threat to any Rh-positive fetus she delivers.
The nurse needs to provide emotional support to help the family deal with the infant"™s condition, which might involve a host of conditions that could lead to death or marked neurological damage.
RhoGam is never given to a woman already sensitized. If not previously sensitized, MICRhoGam (a smaller dose of Rh immune globulin) is given after an abortion or ectopic pregnancy to prevent sensitization. If not sensitized, RhoGam is given to the woman within 72 hours of delivery. Rh-immune globulin is never given to the newborn.
To determine if sensitization has occurred, an Indirect Coombs"™ is drawn on the mother to measure the number of Rh-positive antibodies.
The nurse is caring for a postpartum woman who has relinquished her baby for adoption.
The care plan for the client should include which of the following priority strategies?
Answer : C
Explanation:
Most women who relinquish their infants at birth have come to that decision with a great deal of love and pain. They have made plans in advance.
The nurse needs to first provide them with opportunities to express their feelings that might include grief, loneliness, and guilt.
A referral for grief counseling might be appropriate if no other support system exists or the mother indicates that she wants assistance working through her grief. If the nurse assesses that the grief process is abnormal, a referral is also appropriate.
The mother has probably already made a decision about whether or not she wants to see her baby. The nurse should ask her and make arrangements for that to happen if the mother requests it. Seeing the baby might aid in the grief process. Until relinquishment occurs, this is the mother"™s baby and she should be allowed to see it as often as she wants. The mother does have the right to change her mind until final legal arrangements are made. But suggesting this option might lead her to think that the nurse believes she shouldn"™t relinquish her baby.
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag.
Which of the following nursing actions should the nurse perform first?
Answer : B
Explanation:
Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation.
Laying the infant on her stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. These findings are not normal for a 6-month-old infant.
Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurologic and other metabolic disorders. Some of those disorders might have mental retardation as a component.
However, this child needs to have the referral to determine the cause of the head lag first.
A preschooler has successfully completed the test item "counts 5 blocks" on the Denver II test.
This pass is evidence of which of the following developmental concepts?
Answer : D
Explanation:
The ability to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn"™t change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper or moved to the paper.
Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects.
Causality is based on the sequence of events, one event ordinarily following another.
Nonreversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?
Answer : C
Explanation:
A sense of restored body integrity is an expected outcome for interventions related to disturbed body image.
Adequate tissue perfusion is an outcome for risk of injury and risk of infection, not disturbed body image.
Demonstrating behaviors that might reduce fears is an outcome for anxiety.
Remaining free of infection is an outcome for risk of infection.
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
Answer : A
Explanation:
Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The expected outcome is grief resolution.
Vital signs monitoring is a nursing intervention classification for deficient fluid volume in clients with major burns.
Medication administration: skin is a nursing intervention classification for impaired skin integrity for clients with major burns.
Anxiety reduction is a nursing intervention classification for anxiety experienced by clients with major burns.
When a client who is having trouble conceiving says to the nurse, "I have started taking ginseng," the best response by the nurse is ___________.
Answer : B
Explanation:
Some studies have shown that ginseng and astragalus have enhanced in vitro sperm motility. Ginseng has long been used in traditional Chinese medicine to enhance male fertility. So, Choice "Some studies show that ginseng enhances in vitro sperm motility." is correct and directly addresses the client"™s comments.
Many times couples struggling with infertility turn to alternative therapies in desperation. They can be very expensive, and some are harmful. Ginseng should not interfere with any of the traditional fertility treatments and might help the couple feel empowered that they are also doing something on their own. Choice "No studies show that ginseng is effective for infertility." is not true.
Choice "Why don"™t you try acupuncture instead. Many studies have shown it to be effective for infertility." introduces another alternative therapy. It is true that acupuncture is a traditional Chinese medical therapy and has been shown in several clinical studies to be effective in treating infertility in both women and men.
The best response by the nurse should address the therapy the client states she is using.
Choice "It"™s probably not going to hurt you, but it"™s also probably not going to help. Let"™s look at some other alternatives." dismisses the client"™s attempts to work through her issues and contribute to the solution. One concern is always that more traditional therapies might be ignored, and time might be lost to alternative therapies. But this response causes the client to perceive the nurse as unsupportive and inhibits further discussion and disclosure.
A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm.
The nurse correctly documents the finding as ___________.
Answer : C
Explanation:
Spinnbarkheit is the correct terminology to identify the cervical mucus described. This type of mucus occurs at ovulation and its assessment is used to help couples determine the time they are most likely to conceive.
Ferning capacity or crystallization also increases as ovulation approaches. The only way that ferning can be identified is to place the cervical mucus on a microscope slide, let it air dry, and then examine it for a fern-type appearance.
Lack of ferning cannot be determined without microscopic examination. Inhospitable cervical mucus refers to mazelike patterns of mucoid strands in cervical mucus that prohibit sperm motility.
Other characteristics that make the mucus inhospitable relate to hormone levels, infection, and so on. These conditions cannot be determined by the description supplied in the question.
When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
Answer : A
Explanation:
Sex role identification begins during infancy. Infants can identify body parts by the end of the first year.
Preschoolers frequently engage in masturbation and sex play with peers.
School-age children continue to gain awareness of their sexual identity. During this time, they might continue to masturbate and engage in sex play. They might add behaviors such as hugging and kissing members of the opposite sex.
Adolescent sex role identification is largely influenced by sexual maturation and trying out or assuming a sex role.
When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except
___________.
Answer : A
Explanation:
Many cultures (including the Hispanic and Native-American cultures) are sometimes hesitant to discuss sexuality.
Some Navajos, Hispanics, and Orthodox Jews view the postpartum period as a state of impurity and might seclude women as long as they are bleeding. The seclusion is usually ended with a ritual bath.
Many white teenage girls approve of the prevention of pregnancy, and many African-American teenage girls value pregnancy.
Many Native-American women believe in the importance of monthly menstruation to maintain physical wellbeing and harmony.
Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
Answer : B
Explanation:
Single mothers with two or three children are the fastest-growing segment of the homeless population. The majority of the children are under the age of five, and the total number of children who are homeless account for more than one-third of the homeless population in the United States.
In the past, single adults were the largest group in the homeless population, with more men than women being homeless.
Runaway adolescents account for another group of homeless children. Many are victims of abuse or long-term family or school problems.
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