NURSING 201 Saunders Review Test 1 Questions & Answers (Complete Guide) A+ Work

A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply. A. Not responding to the infant’s cries. Correct B. Crying after talking with spouse on the phone. Correct C. Stating that family was not supportive of the pregnancy. Correct D. Making statements about being fat and unattractive now. Correct E. Stating that that the infant latched on properly during a feeding.
Rationale: The weeks following the birth are a time of vulnerability to psychiatric disorders, such as depression for many women, causing significant distress for the mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional and social development. Mood and anxiety disorders are particularly likely to recur or worsen during these weeks. Such conditions can interfere with attachment to the newborn and family integration, and some may threaten the safety and well-being of the mother, the newborn, and other children. It is important that the nurse frequently assess the client for post-partum depression. Ignoring the infant’s cries should alert the nurse that further assessment is needed. Crying after talking with a spouse of the phone could indicate a problem at home. Statements of non-supportive family members need to be addressed by the nurse, for the safety and well-being of the client and infant. The nurse should also address the client’s statements about body image, educating the client about what is normal and what is not normal in the post-partum period. Stating that the infant latched on during a feeding is a positive action and would not indicate the need for further assessment.
Test-Taking Strategy: Focus on the strategic words, “need for follow-up.” Determine which actions by the client indicate that the client could be experiencing post-partum depression. Eliminate option 5, because this statement is positive and does not indicate that the client is experiencing postpartum depression. Review: Post-partum depression.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity
Giddens Concepts: Clinical Judgment, Mood and Affect
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect
Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 748-749). St. Louis: Elsevier.
Awarded 3.0 points out of 4.0 possible points.
18.ID: 4
The nurse is evaluating a client who is four weeks post-partum. Which statement by the client would indicate a need for intervention? Select all that apply. A. "I feel like giving up." Correct B. "My husband never helps me with the baby." Correct C. "My baby will not stop crying and I can't take it anymore." Correct D. "I wish I could get more than four hours of sleep at a time." E. "My milk has come in and my baby is nursing every 2 hours."
Rationale: Post-partum depression is an intense and pervasive sadness with severe and labile mood swings and is more serious and persistent than postpartum blues. Intense fears, anger, anxiety, and despondency that persist in the new mother past the baby's first few weeks of life are not a normal part of postpartum blues. These symptoms rarely disappear without professional help. The nurse should be aware of statements that could place the well-being of the client and infant at risk, such as wanting to give up or reporting lack of support from a spouse. An inconsolable infant should be evaluated to determine the cause of crying. Most clients in the post-partum period struggle with sleep due to the infant waking up for feedings, which is a normal part of infant life in the first few weeks. An infant who nurses every two hours at four weeks of life is a normal finding and does not require an intervention.
Test-Taking Strategy: Focus on the strategic words, “need for intervention.” Determine which actions by the client indicate that the nurse should intervene. Eliminate options 4 and 5, because these statements are positive and do not indicate a need for the nurse to intervene. Review: post-partum depression.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity.
Integrated Process: Nursing Process/Assessment
Content Area: Maternity
Giddens Concepts: Clinical Judgment, Mood and Affect
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect
Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 749). St. Louis: Elsevier.
Awarded 2.0 points out of 3.0 possible points.
19.ID: 1
The client is being discharged home after the delivery of a healthy infant. The nurse is educating the client on how to prevent postpartum depression. Which activities are the most appropriate for the nurse to suggest? Select all that apply. A. Exercise on a regular schedule Correct B. Eat a healthy, well-balanced diet Correct C. Try to sleep when the baby sleeps Correct D. Don’t overcommit yourself to activities that will be tiring Correct E. Stay home with the baby as much as possible, to promote bonding Incorrect
Rationale: The postpartum nurse must observe the new mother carefully for any signs of tearfulness and conduct further assessments as necessary. Nurses must discuss post-partum depression to prepare new parents for potential problems in the postpartum period. The nurse can provide activities and recommendations to improve the client’s health and well-bring. Exercising on a regular basis will help the client feel better and maintain physical health, as well as eating a healthy diet. The nurse should also suggest avoiding over commitment to activities that will tire the new mother. The nurse should advise the client to sleep when the infant sleeps. While it is important for the client to bond with the infant, the client should not be isolated from friends and family.
Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Determine which activities will assist the client in preventing post-partum depression. Eliminate option 5 because it isolates the client from others and could lead to post-partum depression. Review: Prevention of post-partum depression.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity.
Giddens Concepts: Client Education, Health Promotion
HESI Concepts: Health, Wellness, and Illness – Health Promotion,
Teaching and Learning/Patient Education
Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 748). St. Louis: Elsevier.
Awarded 2.0 points out of 4.0 possible points.
20.ID: 0
The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply. A. Provide the child's parents with a simple dosing schedule. Correct B. Create a medication schedule that fits the parent’s lifestyle. Correct C. Assist the child’s parents in obtaining the medication at an affordable cost. Correct D. Ensure that the child's family is able to read the written discharge instructions. Correct E. Refer the family to the pharmacist with questions about medication side effects. Incorrect
Rationale: Medicating infants and children is an important nursing responsibility. The nurse plays a key role in administering medications, supporting the child and family during the experience, and teaching the child and parents about pharmacologic aspects of the child's care. The nurse should not only coordinate the child's care, but also the discharge process. It is important that the nurse create a medication schedule that fits the family’s lifestyle and provide the family with a simple dosing chart. This helps to ensure that the childreceives proper medication dosing and prevents medication errors. The nurse should consider cost of prescribed medications and providing the family with resources as needed. During the discharge process, the nurse should verify that the family can read the written discharge instructions and answer any questions about the prescribed medications, including side effects.
Test-Taking Strategy: Focus on the subject, “discharge planning“ and “medication instructions.” The discharge process is often complex, the nurse should take actions to simplify this as much as possible. Eliminate options 5, because the nurse should review medications and side effects with the family during the discharge. Although the pharmacist is an excellent resource, it is the nurse’s responsibility to teach about the medication. Review: Discharge teaching.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Giddens Concepts: Care Coordination, Client Education
HESI Concepts:
Collaboration/Managing Care – Care Coordination, Teaching and Learning/Patient Education
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 932-933). St Louis: Mosby.
Awarded 1.0 points out of 4.0 possible points.
21.ID: 0
The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply. A. Assess laboratory values. Correct B. Obtain and assess vital signs. Correct C. Evaluate the client’s venous access. Correct D. Identify the client by room number and bed. E. Check the health care provider’s prescriptions with another nurse. Correct
Rationale: Preparation of the client for transfusion therapy is critical, and institutional blood product administration procedures must be carefully followed. Before administering any blood product, review the agency's policies and procedures. The nurse should take care to ensure that the client is adequately prepared to receive the blood. This is accomplished by assessing the client’s laboratory values, in order to determine the client’s need for intervention. The nurse should be aware of the health care facilities policies and procedures regarding blood administration. The nurse should also obtain and assess the client’s vital signs, prior to blood administration. This is completed so that the nurse can detect any change from the client’s baseline during the administration. The client’s venous access should be assessed prior to the blood administration, ensuring that at least a 20 gauge IV is in place and patent. Checking the health care provider’s prescription with another nurse is a crucial step that must be completed. The nurse should not simply identify the client by room number and bed. The nurse must follow the policies and procedures set by the health care facility for safe blood administration.
Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Determine which actions should be completed by the nurse prior to blood administration. Eliminate option 4, because this step is unsafe and could lead to client harm. The nurse should identify the client using appropriate and safe identifier guidelines. The nurse should take steps to provide for client safety during blood administration. Review: Blood Administration.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Analysis
Content Area: Blood Administration
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 822). St. Louis: Saunders.
Awarded 3.0 points out of 4.0 possible points.
22.ID: 9
The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply. A. The specific dosage Correct B. The client’s home address C. The generic medication name Correct D. The length of time for the administration Correct E. The route and frequency of administration F. Correct