NUR208 EAQ 1: Health and Maintenance Exam Test Questions and
Answers Rated A
Mild preeclampsia
"Preeclampsia is hypertension that develops after 20
A 26-year-old G1 P0 client at 29 weeks' gestation has
weeks' gestation in a previously normotensive woman.
gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has
With mild preeclampsia the systolic blood pressure is
increased from 128/74 Hg to 150/90 mm Hg; and she
below 160 mm Hg and diastolic BP is below 110 mm
has developed 1+ proteinuria on urine dipstick. Which
Hg. Proteinuria is present, but there is no evidence of
condition do these signs suggest?
organ dysfunction. Severe preeclampsia is a systolic blood
1
pressure of greater than 160 mm Hg or diastolic blood
Mild preeclampsia
pressure of at least 110 mm Hg and proteinuria of 5
2
g or more per 24-hour specimen. Chronic hypertension
Severe preeclampsia
is hypertension that is present before the pregnancy or
3
diagnosed before 20 weeks' gestation. Gestational hyper-
Chronic hypertension
tension is the onset of hypertension during pregnancy
4
without other signs or symptoms of preeclampsia and
Gestational hypertension
without preexisting hypertension. Test-Taking Tip: Read
carefully and answer the question asked; pay attention to
specific details in the question."
Which hormone aids in regulating intestinal calcium and
3
phosphorous absorption?
Adrenal glucocorticoids aid in regulating intestinal cal-
1
cium and phosphorous absorption by increasing or de-
Insulin
creasing protein metabolism. Insulin acts together with
2
growth hormone to build and maintain healthy bone tis-
Thyroxine
sue. Thyroxine increases the rate of protein synthesis in all
3
types of tissues. Parathyroid hormone secretion increases
Glucocorticoids
in response to decreased serum calcium concentration
4
and stimulates the bones to promote osteoclastic activity.
Parathyroid hormone
Which information would the nurse base a response on to
1
a mother who asks for guidance regarding who to tell of
The people associated with the school who are interacting
the diagnosis of diabetes of her child, who plays on the
,soccer team?
with the child should be told about the child's condition.
1
Knowledgeable people can be alert for early signs of
Children with diabetes who participate in active sports can
hypoglycemia and have snacks available for the child to
have episodes of hypoglycemia.
help prevent a hypoglycemic episode. Forcing the child to
2
leave the team is a form of discrimination; children with
Children may have to leave athletic teams if school author-
diabetes are allowed to engage in activities as long as their
ities learn that they have diabetes.
diabetes remains under control. The adult who is with the
3
child when the signs of hypoglycemia first appear should
The school nurse will treat the child if clinical findings of
be prepared to treat the child; this person may or may not
hypoglycemia are recognized early.
be the nurse. Information about the child's health status
4
is on a "need to know" basis; professionals are expected
The coach might violate confidentiality by discussing the
to honor confidentiality.
child's condition with other faculty members.
Which domain of the nursing intervention phase includes
Domain 2
electrolyte and acid-base management?
Domain 2 of the nursing intervention phase includes elec-
1
trolyte and acid-base management. Domain 2, or the
Domain 1
physiological complex, includes care that supports home-
2
ostatic regulation. Domain 1 includes care that supports
Domain 2
physical functioning. Domain 3 incorporates care that
3
supports psychosocial functioning and facilitates lifestyle
Domain 3
changes. Domain 4 involves care that supports protection
4
against harm.
Domain 4
With aging, narrowing of the arteries causes some in-
crease in the systolic and diastolic blood pressures. De-
The nurse is preparing to teach a community health pro-
creases occur in diastolic pressure, diastolic filling, and
gram for senior citizens. Which physical findings would
beta-adrenergic stimulation; increases occur in arterial
the nurse include that are typical in older adults?
pressure, systolic pressure, wave velocity, and left ven-
1
tricular end diastolic pressure. Decreased cardiac output
Increased skin elasticity and an increase in testosterone
and cardiac reserve decrease the older adult's response to
stress. Changes in libido may occur. Testosterone appears
, to influence the frequency of nocturnal erections; however,
low testosterone levels do not attect erections produced
production
by erotic stimuli. There is a loss of skin elasticity. By the
2
age of 60, gastric secretions decrease 70% to 80% of those
Impaired fat digestion and an increase in pepsin produc-
of the average adult. A decrease in pepsin may hinder
tion
protein digestion. There may be a decrease in subcuta-
3
neous fat and decreasing body warmth. Some swallowing
Increased blood pressure and decreased cardiac output
diflculties occur because older people are susceptible
4
to fluid loss and electrolyte imbalance. This results from
An increase in body warmth and some swallowing difl-
decreased thirst sensation, diflculty swallowing, chronic
culties
disease, reduced kidney function, diminished cognition,
or adverse medication reactions.
According to Piaget, at approximately 2 years of age
Which cognitive developmental stage would the nurse
the toddler enters the preconceptual phase of cogni-
expect for a 3-year-old child?
tive thought, which lasts, at most, until about 4 years
1
of age; the preconceptual phase is a subdivision of the
Intuitive
preoperational stage, which lasts from 2 years to 7 years
2
of age. Four-year-old children are in the stage of intu-
Abstract
itive thought, which gives rise to imaginative play. Ab-
3
stract thought is developed during the adolescent ages
Concrete
of 15 to 20 years. Concrete operational thought occurs in
4
school-age children when they perform actions mentally
Preconceptual
rather than through behavior, as in the earlier years.
On a routine prenatal visit, which is the sign or symptom
The recognition of fetal movement or quickening com-
that a healthy primigravida at 20 weeks' gestation will
monly occurs in primigravidas at 18 to 20 weeks' ges-
most likely report for the first time?
tation; it is felt about 2 weeks earlier in multigravidas.
1
Palpitations should not occur in the healthy primigravidas.
Quickening
Pedal edema may occur at the end of the pregnancy as the
2
gravid uterus presses on the femoral arteries, impeding
Palpitations
circulation. Immediate follow-up care is required when
3
, Pedal edema
it occurs this early in the pregnancy. Vaginal spotting is
4
abnormal and requires immediate follow-up care.
Vaginal spotting
Which is the most important nursing intervention when
working with an older adult client?
1 Reinforcing strengths promotes self-esteem; reminiscing
Encouraging frequent naps is a therapeutic tool that provides a life review that assists
2 adaptation and helps achieve the task of integrity associ-
Strengthening the concept of ageism ated with older adulthood. Frequent naps may interfere
3 with adequate sleep at night. Reinforcing ageism may
Reinforcing the client's strengths and promoting remi- enhance devaluation of the older adult. A well-balanced
niscing diet that includes protein and fiber should be encouraged;
4 increasing calories may cause obesity.
Teaching the client to increase calories and focusing on a
high-carbohydrate diet
The nurse is teaching a class about nutrition to a group
of adolescents. Taking into consideration the prevalence
of overweight teenagers, which is the best recommenda-
tion?
1
"Join a gym."
Decrease fast-food intake
2
"Drink fewer diet sodas."
3
"Decrease fast-food intake."
4
"Take a multivitamin daily."
4
Which statement is true for collaborative problems in a They are identified by the nurse during the nursing diag-
client? nosis stage.
The nurse assesses the client to gather information for
Answers Rated A
Mild preeclampsia
"Preeclampsia is hypertension that develops after 20
A 26-year-old G1 P0 client at 29 weeks' gestation has
weeks' gestation in a previously normotensive woman.
gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has
With mild preeclampsia the systolic blood pressure is
increased from 128/74 Hg to 150/90 mm Hg; and she
below 160 mm Hg and diastolic BP is below 110 mm
has developed 1+ proteinuria on urine dipstick. Which
Hg. Proteinuria is present, but there is no evidence of
condition do these signs suggest?
organ dysfunction. Severe preeclampsia is a systolic blood
1
pressure of greater than 160 mm Hg or diastolic blood
Mild preeclampsia
pressure of at least 110 mm Hg and proteinuria of 5
2
g or more per 24-hour specimen. Chronic hypertension
Severe preeclampsia
is hypertension that is present before the pregnancy or
3
diagnosed before 20 weeks' gestation. Gestational hyper-
Chronic hypertension
tension is the onset of hypertension during pregnancy
4
without other signs or symptoms of preeclampsia and
Gestational hypertension
without preexisting hypertension. Test-Taking Tip: Read
carefully and answer the question asked; pay attention to
specific details in the question."
Which hormone aids in regulating intestinal calcium and
3
phosphorous absorption?
Adrenal glucocorticoids aid in regulating intestinal cal-
1
cium and phosphorous absorption by increasing or de-
Insulin
creasing protein metabolism. Insulin acts together with
2
growth hormone to build and maintain healthy bone tis-
Thyroxine
sue. Thyroxine increases the rate of protein synthesis in all
3
types of tissues. Parathyroid hormone secretion increases
Glucocorticoids
in response to decreased serum calcium concentration
4
and stimulates the bones to promote osteoclastic activity.
Parathyroid hormone
Which information would the nurse base a response on to
1
a mother who asks for guidance regarding who to tell of
The people associated with the school who are interacting
the diagnosis of diabetes of her child, who plays on the
,soccer team?
with the child should be told about the child's condition.
1
Knowledgeable people can be alert for early signs of
Children with diabetes who participate in active sports can
hypoglycemia and have snacks available for the child to
have episodes of hypoglycemia.
help prevent a hypoglycemic episode. Forcing the child to
2
leave the team is a form of discrimination; children with
Children may have to leave athletic teams if school author-
diabetes are allowed to engage in activities as long as their
ities learn that they have diabetes.
diabetes remains under control. The adult who is with the
3
child when the signs of hypoglycemia first appear should
The school nurse will treat the child if clinical findings of
be prepared to treat the child; this person may or may not
hypoglycemia are recognized early.
be the nurse. Information about the child's health status
4
is on a "need to know" basis; professionals are expected
The coach might violate confidentiality by discussing the
to honor confidentiality.
child's condition with other faculty members.
Which domain of the nursing intervention phase includes
Domain 2
electrolyte and acid-base management?
Domain 2 of the nursing intervention phase includes elec-
1
trolyte and acid-base management. Domain 2, or the
Domain 1
physiological complex, includes care that supports home-
2
ostatic regulation. Domain 1 includes care that supports
Domain 2
physical functioning. Domain 3 incorporates care that
3
supports psychosocial functioning and facilitates lifestyle
Domain 3
changes. Domain 4 involves care that supports protection
4
against harm.
Domain 4
With aging, narrowing of the arteries causes some in-
crease in the systolic and diastolic blood pressures. De-
The nurse is preparing to teach a community health pro-
creases occur in diastolic pressure, diastolic filling, and
gram for senior citizens. Which physical findings would
beta-adrenergic stimulation; increases occur in arterial
the nurse include that are typical in older adults?
pressure, systolic pressure, wave velocity, and left ven-
1
tricular end diastolic pressure. Decreased cardiac output
Increased skin elasticity and an increase in testosterone
and cardiac reserve decrease the older adult's response to
stress. Changes in libido may occur. Testosterone appears
, to influence the frequency of nocturnal erections; however,
low testosterone levels do not attect erections produced
production
by erotic stimuli. There is a loss of skin elasticity. By the
2
age of 60, gastric secretions decrease 70% to 80% of those
Impaired fat digestion and an increase in pepsin produc-
of the average adult. A decrease in pepsin may hinder
tion
protein digestion. There may be a decrease in subcuta-
3
neous fat and decreasing body warmth. Some swallowing
Increased blood pressure and decreased cardiac output
diflculties occur because older people are susceptible
4
to fluid loss and electrolyte imbalance. This results from
An increase in body warmth and some swallowing difl-
decreased thirst sensation, diflculty swallowing, chronic
culties
disease, reduced kidney function, diminished cognition,
or adverse medication reactions.
According to Piaget, at approximately 2 years of age
Which cognitive developmental stage would the nurse
the toddler enters the preconceptual phase of cogni-
expect for a 3-year-old child?
tive thought, which lasts, at most, until about 4 years
1
of age; the preconceptual phase is a subdivision of the
Intuitive
preoperational stage, which lasts from 2 years to 7 years
2
of age. Four-year-old children are in the stage of intu-
Abstract
itive thought, which gives rise to imaginative play. Ab-
3
stract thought is developed during the adolescent ages
Concrete
of 15 to 20 years. Concrete operational thought occurs in
4
school-age children when they perform actions mentally
Preconceptual
rather than through behavior, as in the earlier years.
On a routine prenatal visit, which is the sign or symptom
The recognition of fetal movement or quickening com-
that a healthy primigravida at 20 weeks' gestation will
monly occurs in primigravidas at 18 to 20 weeks' ges-
most likely report for the first time?
tation; it is felt about 2 weeks earlier in multigravidas.
1
Palpitations should not occur in the healthy primigravidas.
Quickening
Pedal edema may occur at the end of the pregnancy as the
2
gravid uterus presses on the femoral arteries, impeding
Palpitations
circulation. Immediate follow-up care is required when
3
, Pedal edema
it occurs this early in the pregnancy. Vaginal spotting is
4
abnormal and requires immediate follow-up care.
Vaginal spotting
Which is the most important nursing intervention when
working with an older adult client?
1 Reinforcing strengths promotes self-esteem; reminiscing
Encouraging frequent naps is a therapeutic tool that provides a life review that assists
2 adaptation and helps achieve the task of integrity associ-
Strengthening the concept of ageism ated with older adulthood. Frequent naps may interfere
3 with adequate sleep at night. Reinforcing ageism may
Reinforcing the client's strengths and promoting remi- enhance devaluation of the older adult. A well-balanced
niscing diet that includes protein and fiber should be encouraged;
4 increasing calories may cause obesity.
Teaching the client to increase calories and focusing on a
high-carbohydrate diet
The nurse is teaching a class about nutrition to a group
of adolescents. Taking into consideration the prevalence
of overweight teenagers, which is the best recommenda-
tion?
1
"Join a gym."
Decrease fast-food intake
2
"Drink fewer diet sodas."
3
"Decrease fast-food intake."
4
"Take a multivitamin daily."
4
Which statement is true for collaborative problems in a They are identified by the nurse during the nursing diag-
client? nosis stage.
The nurse assesses the client to gather information for
