Health Promotion and Maintenance
1.A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before
responding, what
... [Show More] should the nurse consider about the benefits of tetanus antitoxin?
It stimulates plasma cells directly.
A high titer of antibodies is generated.
It provides immediate active immunity.
A long-lasting passive immunity is produced.
Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not
stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by
definition, is not long-lasting.
2.A nurse is determining whether a 5-year-old child is displaying appropriate behaviors for this age. What
developmental findings does the nurse expect? Select all that apply.
Enjoys imitative play
Engages in ritualistic games
Makes up rules for a new game
Asks for a pacifier when uncomfortable
Plays near others quietly but not with them
Imitating adults by playing adult roles in society is at its peak in children 5 years of age; activities are
strongly identified with same-sex parent. A 5-year-old is able to negotiate and use make-believe to play.
These children are able to follow some rules but may cheat to win. Older children in the middle
childhood years need conformity and rituals, whether they play games or amass collections. Rules to
games are fixed, unvarying, and rigid. Knowing the rules means belonging. The use of a pacifier for oral
satisfaction is typical of infants. Parallel play occurs in children ages 2 to 3 years.
3.What is the most appropriate communication strategy for the nurse working with adolescents in a
clinic in a large city health center?
Relating on a peer level
Using typical teenage language
Establishing a relationship over time
Having discussions in concrete terms
Several meetings with an adolescent provide an opportunity to develop trust and establish a
relationship. Relating on a peer level is unrealistic because the nurse is not an adolescent’s peer. Using
teenage language is not necessary and may even impede the establishment of a relationship. It is not
necessary to use concrete terms, because the adolescent is capable of abstract thought.
4.The nurse is examining different statements that represent the stages of psychosexual development,
according to Sigmund Freud’s psychoanalytical model of personality development. Which statement
indicates that the individual is aged between 6 to 12 years?
The individual focuses on educational and social accomplishments.
The individual tries to resolve prior sexual conflicts that have resurfaced.
The individual realizes that the parent is something separate from the self.
The individual fantasizes about the parent of the opposite sex as the first love interest.
According to Sigmund Freud’s psychoanalytical model of personality development, an individual reaches
the latency stage between 6 to 12 years of age. At this stage, the sexual urges of the oedipal stage are
repressed and the individual channels them into socially acceptable productive activities. Therefore, the
child focuses on educational and social accomplishments. When an individual reaches the genital stage,
prior sexual conflicts resurface. He or she tries to resolve them in order to be able to begin an adult
mature relationship. At the oral stage, which begins from birth and continues till 12 to 18 months, the
infant is able to realize that the parent is something separate from the self. An individual between 3 to 6
years old is in the phallic or oedipal stage. At this stage, the child fantasizes about the parent of the
opposite sex as the first love interest.
Which of these features would the nurse state are exhibited by a preschooler?
Temper tantrums
Attempts to control situations
Synchronization of moral skills
Eagerness for formal education
Learn to function independently
Preschoolers refine the mastery of their bodies to function independently and eagerly await the
beginning of formal education.When parents try to control the behavior of a toddler, it leads to temper
tantrums and negative behavior. Toddlers get to know their abilities to control situations and seem
pleased with it. School-aged children and adolescents refine and synchronize physical, psychosocial,
cognitive, and moral skills to become accepted members of society.
What important teaching strategies should the nurse take into consideration to bring a change in the
client’s lifestyle? Select all that apply.
Use written resources at an appropriate reading level.
Practice active listening, and ask the client how he or she prefers to learn.
Refrain from including family member in efforts to bring a change in the client’s lifestyle.
Provide timelines for modification of eating and exercise lifestyle habits without consulting with the
client.
Start with identifying what information the client knows regarding health risks related to poor lifestyle
choices.
To bring a change in the client’s lifestyle, the nurse should use written resources at an appropriate
reading level. The nurse should practice active listening and ask the client how he or she prefers to learn.
The nurse should start by identifying what information the client knows regarding health risks related to
poor lifestyle choices. The nurse should include family members to help bring changes in the client’s
lifestyle. The nurse should provide timelines for modification of eating and exercise lifestyle habits after
consulting with the client.
6.A parent expresses concern that the adolescent child is not ingesting enough calcium because of an
allergy to milk. What alternative foods or liquids should the nurse suggest? Select all that apply.
Cottage cheese
Green leafy vegetables
Black or baked beans
Yogurt
Oranges
Salmon and sardines
Green leafy vegetables, black and baked beans, oranges, and salmon and sardines are all good sources of
calcium even though they do not contain milk or milk products. Cottage cheese and yogurt both contain
milk and therefore must be eliminated.
9.A client asks a nurse about the most common problem associated with the use of an intrauterine
device (IUD). What answer should the nurse provide?
Perforation of the uterus
Spontaneous device expulsion
Discomfort associated with coitus
Development of vaginal infections
The IUD may cause irritability of the myometrium, inducing contraction of the uterus and expulsion of
the device. Perforation of the uterus is a rare, rather than a common, occurrence. Clients do not report
discomfort during coitus when an IUD is in place. Increased incidence of vaginal infections is not
reported with the use of an IUD.
10.A couple interested in family planning asks the nurse about the cervical mucus method of family
planning. The nurse explains that with this method the couple must avoid intercourse when and a few
days after the cervical mucus is what?
Clear and thick
Yellow and thin
Cloudy and viscid
Clear and stretchable
The cervical mucus is clear and stretchable (spinnbarkeit) at ovulation because of maximal estrogen
stimulation. Clear, thick cervical mucus occurs after ovulation has occurred. Yellow, thin cervical mucus
does not occur at any specific point during the menstrual cycle and may indicate an infection.
The parents of a school-age child tell the nurse, "My child seems very hot or red in the face, has
abdominal pain, and appears jittery." What does the nurse suggest as the reason for the child’s signs and
symptoms?
"The child is experiencing stress in some area of life."
"The child is growing up and feels the need for autonomy."
"The child may be eating mostly junk food out of the house."
"The child may be staying up late at night to watch television."
Appearing hot or red in the face and jittery, along with abdominal pain, indicates that the child is
experiencing stress. The parents need to talk about any stressors that the child is experiencing and
should encourage the use of effective problem-solving and coping skills. Staying up late at night and
watching television may cause fatigue, but not abdominal pain or jitteriness. The school-age child does
not seek autonomy and shares most things with the family. Eating junk food out of the house may result
in obesity or unhealthy eating habits.
2.What nursing intervention best meets a major developmental need of a newborn in the immediate
postoperative period?
Giving a pacifier to the infant
Putting a mobile over the infant's crib
Providing the infant with a soft, cuddly toy
Warming the infant's formula before feeding
Sucking meets oral needs, which are primary during infancy. An infant a few days old is too young to
focus well on a mobile; in addition, the newborn will be placed in a side-lying position after surgery and
therefore would not be able to see a mobile. A newborn is not developmentally capable of enjoying a
soft, cuddly toy. Warming the infant's formula before feeding does not satisfy a developmental need.
3.A nurse is caring for a hospitalized school-aged child. What development-related activity is most
important for the nurse to encourage?
Family contact
Peer interaction
Therapeutic play
Academic studies
School-aged children have a need to be successful in school; this will help ensure that the child keeps up
with the work being presented in class. Although contact with family is important, the school-aged child
is beginning to move away from the family and into other realms. Although peer and social interactions
and play are important, industrious activities and educational success are more important at this age.
The school-aged child does not benefit from therapeutic play as much as the preschooler does. At this
age the child can understand a simple explanation of treatment, although it is helpful to be shown and to
handle the equipment.
5.A student nurse compares the sources of stress in both 7-year-olds and 12-year-olds. Which source of
stress is prevalent in children of both these age groups?
Idols
Health
Money
Confusion
Idols are a source of stress for both 7-year-old and 12-year–old children. The 7-year-old has a desire to
be more like an admired idol. The 12-year-old continues hero worshipping. Health is a source of stress
for 12 year olds and some may become hypochondriacs during this period of development. Health is not
a source of stress for 7 year olds. Money can be a source of stress for the 12 year old. This child is
anxious to earn and handle money but often uses poor judgment. Money is not yet a matter of concern
for the 7 year old. Too much freedom can create confusion in a 12-year-old and can cause the child to
flounder. A 7-year-old does not usually have much freedom and, thereby, does not experience the
accompanying stress.
7.A nurse in the women's health clinic is counseling clients about family planning. What should the nurse
consider when discussing the effects of a high concentration of estrogen in the blood?
It causes ovulation.
Lactation is stimulated.
It prompts secretion of oxytocin.
It inhibits secretion of follicle-stimulating hormone (FSH).
A high level of plasma estrogen inhibits anterior pituitary secretion of FSH; this effect appears to be
mediated by the hypothalamus and its releasing factors. Luteinizing hormone, not estrogen, causes
ovulation. Lactogenic hormone (prolactin) stimulates lactation. Putting the infant to the breast prompts
the release of oxytocin, which is secreted by the posterior pituitary gland, resulting in the let-down
reflex.
8.Which statements should the nurse include in a teaching session for pregnant couples regarding fetal
growth and development? Select all that apply.
"All major organs are developed and function prior to birth."
"Development occurs in a head-to-toe and central-to-peripheral pattern."
"The fetal stage of development is most vulnerable to teratogenic influences."
"Pregnancy includes the preembryonic, embryonic, and fetal stages of development."
"During pregnancy the embryo grows from a single cell to a complex physiologic being."
Information the nurse should include in a teaching session regarding fetal growth and development
during pregnancy includes that development occurs in a head-to-toe (cephalocaudal) and central-toperipheral (proximal-distal) pattern; the three stages of pregnancy include the preembryonic, embryonic,
and fetal stages of development; and the embryo grows from a single cell to a complex physiologic
being. While all major organs do develop during pregnancy not all function prior to birth. The embryonic,
not the fetal, stage of development is most vulnerable to teratogenic influences.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease.
Which foods would be appropriate to include in the teaching plan? Select all that apply.
Whole grains
Cooked fruits and vegetables
Nuts and seeds
Lean red meats
Milk and eggs
With diverticular disease, the client should avoid foods that may obstruct the diverticuli. Therefore the
fiber should be digestible, such as whole grains and cooked fruits and vegetables. Milk and eggs have no
fiber content but are good sources of protein. For clients with diverticular disease, nuts and seeds are
contraindicated, because they may be retained and cause inflammation and infection, which is known as
diverticulitis. The client should also decrease intake of fats and red meats.
3.A nursing student is listing the steps that need to be followed for applying developmental theory when
caring for chronically ill older adults with depression. Which step listed by the nursing student needs
correction?
"The nurse should understand adult development and its implications for practice."
"The nurse should be aware of signs of depression such as general fatigue or insomnia."
"The nurse should recognize the need to identify depression so that heart failure can be prevented."
"The nurse should understand the older adult’s concept of depression and views on treatment for
mental illness."
The nurse should recognize the need to identify depression so that appropriate treatment can be
provided to the older adults. Congestive heart failure is not caused by depression. The nurse should
understand adult development and its implications for practice when applying developmental theory.
The nurse should be aware of signs of depression such as general fatigue or insomnia. The nurse should
understand the older adult’s concept of depression and views on treatment for mental illness as it helps
him or her to get complementary and alternative treatment measures.
5.Because of a measles epidemic, a 6-month-old infant receives measles immunoglobulin. The nurse
should help the parents understand that to ensure continuous protection against measles, the infant
should be revaccinated around what age?
8 months
10 months
12 months
18 months
The optimal age for measles vaccination is between 12 and 15 months; if prophylaxis is given earlier
because of exposure to a person with measles, it is not counted as one of the two required doses. Eight
months and 10 months are too early; the infant will still have antibodies from the previous vaccination.
Eighteen months is not the optimal time; the measles immunization should be given between 12 and 15
months.
7.During a routine physical examination a 10-year-old girl is discovered to have scoliosis. The curve is
diagnosed as mild and functional, and a daily exercise program is established. The next month at the
follow-up visit, what statement made by the girl helps the nurse determine that the child is complying
with the exercise program?
"I like doing my exercises with my brother so he can get stronger."
"I think my exercises will make me a better softball and soccer player."
"I do my exercises every day while my mother stays with me and watches."
"I count out loud when I do my exercises so my mother can hear that I'm doing them all."
The child is anticipating improvement; this reflects positive internal motivation, which helps maintain the
child's interest and willingness to continue with the program. Motivation may diminish if the focus is on
the brother rather than on the child's need to do the exercises. Doing the exercises to please the mother,
as evidenced by having the mother watch every day or listen to the daughter counting to show that the
exercises are being done, is external motivation, which is not as desirable as internal motivation.
10.The nurse instructs the son of an older client about age-related immune system changes and
associated care measures. Which statement made by the son during a follow-up visit indicates a need for
further instruction?
"My parent has a private room at home."
"My parent has received the pneumococcal vaccination recently."
"My parent comes in for check-ups only whenever he or she has a fever."
"My parent has been given a second dose of the pertussis vaccination."
Older clients should have regular check-ups even in the absence of fever. Because aging causes reduced
neutrophil function, some infections may not show fever symptoms. Older adults should have a private
room at home to avoid other adults who may have viral infections. Because older adults have a
decreased production of antibodies against new antigens, the caretaker should ensure that the older
client has received updated vaccinations against infectious diseases such as pneumococcus and pertussis
What is the similarity between the formal operations period and the preoperational period according to
Piaget’s theory?
Both the periods describe "imaginary audience."
Both the periods demonstrate "animism" in a child.
Both the periods explain egocentric thought of an individual.
Both the periods occur in the beginning of cognitive development.
The preoperational period and formal operations period explain the egocentric thought. The
preoperational period describes "egocentrism" in a child at the age of 2 to 7 years; the formal operations
period explains the egocentric thought from 11 years of age to adulthood. During the formal operations
period, an individual believes that his/her actions and appearance are constantly being scrutinized by an
"imaginary audience," which is not seen during the preoperational period. The preoperational period,
not the formal operations period, tells about "animism" where the child thinks that there is life in every
inanimate object. The preoperational period marks the beginning of the cognitive development, whereas
formal operations period marks the end of cognitive development.
4.Which fine motor skill lacking in a 6-month-old infant would cause the nurse concern?
Lack of a pincer grasp
Inability to hold a bottle
Lack of a hand preference
Inability to pick up small objects
The nurse would anticipate that a 6-month-old infant would be able to hold a bottle; therefore, this
would cause the nurse concern. Lack of a pincer grasp, lack of hand preference, and the inability to pick
up small objects would not cause the nurse concern at this time.
6.What is the similarity between evidence-based practice (EBP) and quality improvement (QI)?
Both receive funding from internal sources.
Both use data sources from multiple research studies.
Both need approval of the institutional review board.
Both are conducted by researchers employed for this purpose.
Both evidence-based practice (EBP) and quality improvement (QI) are funded by internal sources. EBP
uses information from multiple research studies; in contrast, QI collects data from client records. EBP
does not require the institutional review board approval; QI sometimes may require institutional review
board approval. EBP and QI are carried out by practicing nurses and possibly other members of the
healthcare team. Research studies are carried out by researchers.
8.A school nurse is screening children for scoliosis. In what age group is it usually identified?
Adolescence
Preadolescence
Early school years
Middle school years
Preadolescence is the time when scoliosis is most likely to become evident because of the growth spurt
that occurs at this time. Although scoliosis may occur at any age, idiopathic scoliosis, the most common
type, tends to become evident during the preadolescent growth spurt.
9.A young child presents with a blood lead level (BLL) of 17 mcg/dL. The nurse is aware that the client’s
BLL levels have remained at this level in two samples obtained 4 months apart. Which actions will the
nurse take to provide appropriate care for this client? Select all that apply.
Refer client to social services.
Refer client to a clinical center specializing in lead poisoning.
Consider treating with appropriate chelation therapy.
Perform follow-up testing within 1 month, then every 3 to 4 months.
Immediately provide diagnostic testing and initiate chelation therapy.
The Centers for Disease Control and Prevention (CDC) have recommended various actions to be taken
depending on the BLL of the client. While a BLL of 17 mcg/dL falls in the range of BLL 15-19 mcg/dL, the
nurse needs to follow the guidelines for 20 to 44 mcg/dL if BLL remains 15 mcg/dL or higher on two
samples obtained at least 3 months apart. The client in this case has had a BLL of 17 mcg/dL on two
samples obtained 4 months apart, so, based on the guidelines for 20 to 44 mcg/dL, the nurse will refer
the client to a clinical center specializing in lead poisoning and will also consider treating him or her with
appropriate chelation therapy. The nurse would have simply referred the client to social services and
performed follow-up testing within 1 month, then every 3 to 4 months, if the guidelines for BLL 15-19
mcg/dL had been followed. The nurse would immediately provide diagnostic testing and initiate
chelation therapy if BLL is 70 mcg/dL or higher.
1.An infant born with exstrophy of the bladder is admitted to the pediatric unit for urinary diversion
surgery in which the ureters are to be transplanted to a resected section of the small intestines, with one
end attached to the abdominal wall. What does the nurse call the procedure when explaining the
surgery to the parents?
Cystostomy
Ileal conduit
Ureterosigmoidostomy
Cutaneous ureterostomy
An ileal conduit is the transplantation of the ureters into a resected portion of the ileum, which is then
used to create a stoma on the abdominal wall for drainage of urine. Cystostomy is an opening into the
bladder through the abdominal wall that allows urine to flow out. In ureterosigmoidostomy the ureter is
transplanted into the colon and urine is excreted through the rectum. In cutaneous ureterostomy the
ureter is transplanted through the abdomen and attached to the skin.
4.A nurse manager notices that a previously effective nurse appears to be distracted, at times forgets to
document changes in clients’ status, and rarely completes the required workload without help from
another nurse. What should the nurse manager say to the nurse?
"You seem to be having difficulty completing your assignments. What can I do to help?"
"Why are you having trouble fulfilling your assignment? I need to know what’s going on."
"Call me to help you organize your day—then you’ll have time to complete your assignment."
"I’ve noticed that you always give part of your workload to another nurse. This is unacceptable."
An understanding and supportive approach to a colleague helps the individual identify and address the
problem. Asking why the nurse is having trouble fulfilling her assignment and what is going on is an
accusatory approach. Implying a lack of organizational skills may or may not be accurate; also, it is an
accusatory approach. Observing that the nurse always gives part of her workload to another nurse and
noting that this is unacceptable states a fact of which the individual is probably aware; it may interfere
with self-identification of the problem and is accusatory.
What are the similarities between evidence-based practice and quality improvement? Select all that
apply.
Nurses conduct the activities in both.
Funding resources are internal in both.
The effects of the practice are measured in both.
Expert opinions are the data resources in both.
Institutional Review Board approval is needed for both.
In both evidence-based practice and quality improvement, practicing nurses conduct the activities. The
funding resources in evidence-based practice and quality improvement are internal, that is, from the
health care agency itself. The measurement of the effects of practice or any change in practice regarding
clients is done in quality improvement only. Data resources in evidence-based practice are based on
expert opinions, personal experience and clients. In quality improvement, the data is collected from
client records or clients from a specific area such as the intensive care unit. Institutional Review Board
approval is only needed for evidence-based practice.
3.The nurse manager found that the nursing assistant (NA) shows unwillingness and is not motivated to
go beyond the job description to take care of a client during the night. Which strategy by the nurse
leader would motivate the NA and create job satisfaction?
Ask the authorities to recruit more staff.
Ask the authorities to increase the security needs at night.
Ask the nursing assistant (NA) to participate in decision making.
Ask the authorities to increase the salary of the nursing assistant (NA).
According to the two-factor theory of leadership, motivating factors such as recognition and satisfaction
of work promote job enrichment and create job satisfaction. Hygiene factors such as recruiting more
staff to balance the work for nursing assistants (NAs), increasing the NA’s salary, and increasing the
security needs at night only avoid job dissatisfaction; these factors do not necessarily motivate the NA.
5.The nurse leader working in a 30-bed intensive care unit accrued 792 client days in January. What is the
percentage of occupancy calculated by the leader nurse? Record your answer using a whole number.
_85____%
The formula is average daily census (ADC) (rounded) divided by the number of beds in the unit
multiplied by 100. ADC equals the client days in a given time period divided by the number of days in the
time period. Therefore 792/30 = 25.5. Therefore the percentage of occupancy is 25.5/30 x 100 = 85%
Which statements indicate that the nurse leader is adapting to changes in leadership practices to adjust
to complex changes in healthcare systems? Select all that apply.
"I will stop tracking progress."
"I will be clear about purpose and process."
"I will involve stakeholders and listen to them."
"I will stop utilizing and providing older resources."
"I will align systems and processes to support the change."
The nurse leader should be clear about the purpose and processes in order to adjust to complex
changes. This clarity will help the nurse leader implement the desired changes efficiently and effectively.
Listening to the stakeholders and involving them helps the nurse leader understand the changes
properly. Aligning systems and processes to support the change is an effective way to implement the
change. Tracking progress helps the nurse analyze whether the change is being implemented properly.
Utilization of both new and older resources is required to implement the changes effectively.
3.A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning
sensation above the IV site. What should the nurse do first?
Check the IV access for a blood return
Apply warm compresses to the affected extremity
Slow the IV infusion until the burning sensation is gone
Request an oral supplement from the primary healthcare provider
Because potassium infusions can be caustic to the vein, a nurse should check for continued blood return.
That finding determines the nurse's next intervention(s). If blood return is present, then it is appropriate
to apply warm compresses. If there is not a blood return, the infusion needs to be stopped via that IV
site, not slowed. If the potassium infusion cannot be administered, the primary healthcare provider must
be notified so that other means of potassium replacement can be instituted. [Show Less]