Ma Wee

1. After the nurse instructs a 20 year old nuligravid client on how to perform a breast self examination which of the following client statements indicates that the teaching has been effective? a. ) I should perform breast self examination on the day my menstrual flow begins . b. ) Its important that I perform breast self examination c. ) If I notice that one of my breast is much smaller than the other I shouldn’t worry . d. ) If there’s some discharge from my nipples I should avoid squeezing them. Answer: D. Rationale: If a client notices a discharge or bleeding . she should notify physician this may be symptomatic of underlying disease. 2. A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant? A) Estrogen B) HCG C) Alpha-fetoprotein D) Progesterone Review Information: The correct answer is B: HCG Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy. 3. The visiting nurse makes a postpartum visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The initialnursing intervention would be to A) call the police to report indications of domesticviolence B) confront the husband about abusing his wife C) leave the home because of the unsafe environment D) interview the client alone to determine the originof the injuries Review Information: The correct answer is D: interview the client alone to determine the originof the injuries It would be wrong to assume domestic violencewithout further assessment. Separate the suspectedvictim from the partner until battering has been ruled out. 4. The client asks the nurse how the health careprovider could tell she was pregnant “just bylooking inside.” What is the best explanation bythe nurse? A) Bluish coloration of the cervix and vaginalwalls B) Pronounced softening of the cervix

C) Clot of very thick mucous that obstructs thecervical canal D) Slight rotation of the uterus to the right Review Information: The correct answer is A: Bluish coloration of the cervix and vaginal walls Chadwick>>s sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4weeks of pregnancy, that is caused by vasocongestion 5. A 52 year-old post menopausal woman asks thenurse how frequently she should have a mammogram.What is the nurse>s best response? A) «Your doctor will advise you about your risks.» B) «Unless you had previous problems, every 2years is best.» C) «Once a woman reaches 50, she should have a mammogram yearly.» D) «Yearly mammograms are advised for all women over 35.» Review Information: The correct answer is C: «Once a woman reaches 50, she should have a mammogram yearly.» The American Cancer Society recommends a screening mammogram by age 40, every 1 – 2 years for women 40-49, and every year from age 50. If there are family or personal health risks, other assessments may be recommended. 6. The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching? A) Cocaine use can cause fetal growth retardation B) The drug has been linked to neural tube defects C) Newborn withdrawal generally occurs immediately after birth D) Breast feeding promotes positive parenting behaviors Review Information: The correct answer is A: Cocaine use can cause fetal growth retardation Cocaine is vasoconstrictive, and this effect in the placental vessels causes fetal hypoxia and diminished growth. Other risks of continued cocaine use during pregnancy include preterm labor, congenital abnormalities, altered brain development and subsequent behavioral problems in the infant.

7. A 7 month pregnant woman is admitted with plaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen

Review Information: The correct answer is B: Abdominal ultrasound. The standard for diagnosis of placenta previa, which is suggested in the client>>s history of painless bleeding, is abdominal ultrasound. 8. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states «This is not my baby, and I do not want it.» After repositioning the child safely, the nurse>s best response is A) «This is a common occurrence after birth, but you will come to accept the baby.» B) «Many women have postpartum blues and need some time to love the baby.» C) «What a beautiful baby! Her eyes are just like yours.» D) «You seem upset; tell me what the pregnancy and birth were like for you.» Review Information: The correct answer is D: «You seem upset; tell me what the pregnancy and birth were like for you.». A non-judgmental, open ended response facilitates dialogue between the client and nurse. 9. The nurse is reinforcing teaching to a 24 year-oldwoman receiving acyclovir (Zovirax) for a HerpesSimplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least 5 years after the diagnosis Review Information: The correct answer is B: Begin treatment with acyclovir at the onset of symptoms of recurrence. When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease; they simply decrease the level of symptom

10. Before advising a 24 year old client desiring oral contraceptives for family planning the nurse would asses the client for signs & symptoms of which of the ff? a.) Anemia b.) Hypertension c.) Dysmennorhea d.) Acne vulgaris Answer: B

Rationale: Before advising client about oral contraceptives the nurse needs to asses for signs and symptoms of hypertension . Clients who has hypertension , thrombo phlebitis , obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. 11. The nurse instructs a primigravid client to increase her intake of foods high in magnesium because of its role with which of the following ? a. Prevention of demineralization of mother bones . b. Synthesis of proteins nucleic acid and fats c. Amino acid metabolism d. synthesis of neural pathways in fetus. Answer: B Rationale : Magnesium aids in the synthesis of protein ,nucleic acids fats . it is important for cell growth and neuromuscular function. 12. When developing a meal planning guide about foods rich in riboflavin for a primigravid client , the nurse would expect to instruct the client to atleast include 2 daily servings of which of the ff? a. Fresh fruit b. Prunes c. Potatoes d. Enriched cereals Answer: D Rationale: Riboflavin forms co enzyme need to release energy . Enriched grain products ( e.g cereals breads, deep green leafy veggies, milk, veal, beef & cheddar cheese are rich sources of riboflavin. Fresh fruit is rich in vit c and fiber. Prunes is rich in vit c and iron. Potatoes are source of vit c and carbo.