Q&a Health Promotion Maintenance

Results for Lesson 3: Health Promotion and Maintenance Questions are numbered by the order in which they appeared in the test. Represents the correct answer. Question 1 While the nurse is administering medications to a client, Answers Correct C the client states "I do not want to take that medicine today." Student's C Which of the following responses by the nurse would be best? "That's OK, its all right to skip your medication now A) and then." B) "I will have to call your doctor and report this." "Is there a reason why you don't want to take your C) medicine?" "Do you understand the consequences of refusing D) your prescribed treatment?" Review Information: The correct answer is C: "Is there a reason why you don''t want to take your medicine?" When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 2

A 64 year-old client scheduled for surgery with a general Answers Correct D anesthetic refuses to remove a set of dentures prior to Student's B leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? Explain to the client that the dentures must come out A) as they may get lost or broken in the operating room Ask the client if there are second thoughts about B) having the procedure Notify the anesthesia department and the surgeon of C) the client's refusal Ask the client if the preference would be to remove D) the dentures in the operating room receiving area Review Information: The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving area Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and selfconcept. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 3 The nurse is teaching the parents of a 3 month-old infant Answers Correct A about nutrition. What is the main source of fluids for an Student's A infant until about 12 months of age? A) Formula or breast milk B) Dilute nonfat dry milk C) Warmed fruit juice D) Fluoridated tap water Review Information: The correct answer is A: Formula or breast milk Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 4

The nurse is assessing a 4 month-old infant. Which motor Answers Correct A skill would the nurse anticipate finding? Student's A A) Hold a rattle B) Bang two blocks C) Drink from a cup D) Wave "bye-bye" Review Information: The correct answer is A: Hold a rattle The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 5 A client is admitted to the hospital with a history of Answers Correct D confusion. The client has difficulty remembering recent Student's D events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A) "Good morning. Do you remember where you are?" "Hello. My name is Elaine Jones and I am your nurse B) for today." "How are you today? Remember, you're in the C) hospital." "Good morning. You’re in the hospital. I am your D) nurse Elaine Jones." Review Information: The correct answer is D: "Good morning. You’re in the hospital. I am your nurse Elaine Jones." As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location and the caregiver’s name. Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 6

The family of a 6 year-old with a fractured femur asks the Answers Correct B nurse if the child's height will be affected by the injury. Student's B Which statement is true concerning long bone fractures in children? Growth problems will occur if the fracture involves A) the periosteum Epiphyseal fractures often interrupt a child's normal B) growth pattern Children usually heal very quickly, so growth C) problems are rare Adequate blood supply to the bone prevents growth D) delay after fractures Review Information: The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it can interrupt and alter growth. Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 7 The nurse has been teaching adult clients about cardiac Answers Correct D risks when they visit the hypertension clinic. Which Student's D evaluation data would best measure learning? A) Performance on written tests B) Responses to verbal questions C) Completion of a mailed survey D) Reported behavioral changes Review Information: The correct answer is D: Reported behavioral changes If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction. Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 8

When screening children for scoliosis, at what time of Answers Correct D development would the nurse expect early signs to appear? Student's C A) Prenatally on ultrasound B) In early infancy C) When the child begins to bear weight D) During the preadolescent growth spurt Review Information: The correct answer is D: During the preadolescent growth spurt Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 9 When teaching effective stress management techniques to Answers Correct B a client 1 hour before surgery, which of the following Student's B should the nurse recommend? A) Biofeedback B) Deep breathing C) Distraction D) Imagery Review Information: The correct answer is B: Deep breathing Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 10 When teaching a 10 year-old child about their impending Answers Correct D heart surgery, which form of explanation meets the Student's A developmental needs of this age child? A) Provide a verbal explanation just prior to the surgery Provide the child with a booklet to read about the B) surgery Introduce the child to another child who had heart C) surgery 3 days ago D) Explain the surgery using a model of the heart Review Information: The correct answer is D: Explain the surgery using a model of

the heart According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 11 The nurse is assessing a client who states her last menstrual Answers Correct D period was March 16, and she has missed one period. She Student's D reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? A) April 8 B) January 15 C) February 11 D) December 23 Review Information: The correct answer is D: December 23 Naegele''s rule states: Add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery. Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 12 When observing 4 year-old children playing in the hospital Answers Correct D playroom, what activity would the nurse expect to see the Student's D children participating in? A) Competitive board games with older children Playing with their own toys along side with other B) children C) Playing alone with hand held computer games D) Playing cooperatively with other preschoolers Review Information: The correct answer is D: Playing cooperatively with other preschoolers Cooperative play is typical of the late preschool period. Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition).

Philadelphia, PA: Lippincott Williams & Wilkins. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 13 A client states, "People think I’m no good, you know what Answers Correct C I mean?" Which of these responses would be most Student's C therapeutic? "Well people often take their own feelings of A) inadequacy out on others." "I think you’re good. So you see, there’s one person B) who likes you." "I’m not sure what you mean. Tell me a bit more C) about that." "Let's discuss this to see the reasons you create this D) impression on people." Review Information: The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that." This therapeutic communication technique elicits more information, especially when delivered in an open, non-judgmental fashion. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 14 A client being treated for hypertension returns to the Answers Correct A community clinic for follow up. The client says, "I know Student's A these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis? A) Noncompliance related to medication side effects Knowledge deficit related to misunderstanding of B) disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation Review Information: The correct answer is A: Noncompliance related to medication side effects The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins. Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

Question 15 A partner is concerned because the client frequently Answers Correct A daydreams about moving to Arizona to get away from the Student's A pollution and crowding in southern California. The nurse explains that such fantasies can gratify unconscious wishes or A) prepare for anticipated future events detaching or dissociating in this way postpones B) painful feelings converting or transferring a mental conflict to a C) physical symptom can lead to conflict within the partnership isolating the feelings in this way reduces conflict D) within the client and with others Review Information: The correct answer is A: such fantasies can gratify unconscious wishes or prepare for anticipated future events Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes. Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall. Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

Question 16 The nurse is planning care for an 18 month-old child. Answers Correct B Which action should be included in the child's care? Student's C A) Hold and cuddle the child frequently B) Encourage the child to feed himself finger food Allow the child to walk independently on the nursing C) unit D) Engage the child in games with other children Review Information: The correct answer is B: Encourage the child to feed himself finger food According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control. Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.

(5th edition). St. Louis, Missouri: Mosby. Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Question 17 An appropriate treatment goal for a client with anxiety Answers Correct C would be to Student's A A) ventilate anxious feelings to the nurse B) establish contact with reality C) learn self-help techniques D) become desensitized to past trauma Review Information: The correct answer is C: learn self-help techniques Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn self-help techniques will assist in learning to cope with anxiety. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby. Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

Question 18 While caring for a client, the nurse notes a pulsating mass Answers Correct B in the client's periumbilical area. Which of the following Student's B assessments is appropriate for the nurse to perform? A) Measure the length of the mass B) Auscultate the mass C) Percuss the mass D) Palpate the mass Review Information: The correct answer is B: Auscultate the mass Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins. Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Question 19 A client with congestive heart failure is newly admitted to Answers Correct C home health care. The nurse discovers that the client has Student's C not been following the prescribed diet. What would be the most appropriate nursing action? Discharge the client from home health care because A) of noncompliance Notify the provider of the client's failure to follow B) prescribed diet Discuss diet with the client to learn the reasons for C) not following the diet D) Make a referral to Meals-on-Wheels Review Information: The correct answer is C: Discuss diet with the client to learn the reasons for not following the diet When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client''s behavior and feelings as a basis for future teaching and intervention. Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby. Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Question 20 The parents of a child who has suddenly been hospitalized Answers Correct D for an acute illness state that they should have taken the Student's D child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments? A) Focus on the child's needs and recovery B) Explain the cause of the child's illness C) Acknowledge that early care would have been better D) Accept their feelings without judgment Review Information: The correct answer is D: Accept their feelings without judgment Parents often blame themselves for their child''s illness. Feeling helpless and angry is normal and these feelings must be accepted. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.