Health Promotion and Maintenance Questions & Answers

Health Promotion and Maintenance Questions & Answers The nurse is assessing a female school-aged client. The client has large breast development, is in the 95th percentile for height and weight, wears braces, and reports amenorrhea at this time. Which of the following questions should the nurse ask to assess the client's reaction to these age-related changes? A. "Are you happy your teeth will look perfect when your braces are removed?" B. "Would you like to talk about your breast development?" C. "Do your friends talk about having their menses yet?" D. "How are you feeling about your height and weight?" D. Rationale: The child is in the 95th percentile for height and weight, which would indicate she is taller and heavier than most females her age. The nurse should ask the child to describe her feelings about her height and weight. The other questions are closed-ended that only require a yes or no and do not facilitate communication about how the child feels. A rehabilitation nurse is caring for a client who has left-sided neglect after experiencing a cerebrovascular accident (CVA). Which of the following interventions would the nurse include from the plan of care to address the client's motor and sensory deficits? A. Encourage the client to strengthen the unaffected side B. Remind the client to look to their left C. Have the client perform ADLs independently D. Assist the client to dress the unaffected side first B. Rationale: Homonymous hemianopsia (blindness in half of the visual field in one or both eyes) may occur from stroke and may be temporary or permanent. The affected side of vision loss corresponds to the paralyzed side of the body leading to unilateral neglect. Interventions are aimed at promoting safety and independence through prompts for visual scanning (look to the affected side), encouraging the client to dress in front of a mirror to identify the affected side, and promoting the use and exercise of the affected side. Clients should work to perform ADLs independently and dress the affected side first. A nurse is performing psychosocial assessments on several clients in an obstetric clinic. Based on the history obtained, which client is at risk for impaired coping during pregnancy? A. A client who verbalizes feeling irritable and has lost sexual desire towards her partner B. A client who lives in a multi-generational household and believes pregnancy is a transitional period of illness C. A client with a history of sexual abuse who is highly involved in her church community D. A client with a history of depression who is married and has two other children B. Rationale: Hormonal changes during pregnancy and cultural norms can decrease the client's ability to cope. Strong social support from family, friends, and community members can assist the client during overwhelming mood swings. A client who believes pregnancy is an illness will have difficulty coping and adjusting to her new lifestyle. Cultural beliefs should be assessed, and unsafe practices should be further evaluated. Mood swings and loss of sexual desire are common responses to hormonal changes during pregnancy. The nurse should encourage stress relieving strategies. While previous history of sexual assault may cause anxiety during the birthing process, a strong social support system can help the client cope. Although the client has a history of depression, the client has a support system as indicated by a partner and children. During a nonstress test conducted at 37 weeks gestation, the client reports fetal movement 3 times. The nurse notes that when the expectant mother reports fetal movement, the fetal heart rate (FHR) increases 15 beats or more above the baseline. The nurse concludes that this test finding is which of the following? A. FHR variability B. FHR decelerations C. A nonreactive pattern D. A reactive pattern D. Rationale: Prenatal non-stress testing (NST) is a non-invasive method used to test fetal well-being before the onset of labor. An NST functions as a part of the biophysical profile. NST can be used from 32 weeks gestation to term to detect the presence of fetal movements and assess fetal heart rate acceleration. The test is used to determine if a fetus is at risk for intrauterine death or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal hypoxemia. NSTs are frequently used because of the low maternal and fetal risk. The NST involves 20 minutes of monitoring the FHR while assessing the number, amplitude, and duration of accelerations that usually correlate with fetal movement. A normal, reactive NST indicates fetal activity as evidenced by two or more accelerations peaking at 15 bpm or more above baseline, each lasting 15 seconds or more, and all occurring within 20 minutes of beginning the test. It is important to note that an abnormal stress test is not always ominous and can occur with a sleeping fetus. If a test is not reactive, FHR should be monitored for at least 40 minutes to account for the fetus's sleep cycle. The nurse is caring for a gravida 2 para 1 client in the 10th week of her pregnancy who states, "I've never urinated as often as I have for the past three weeks." Which response would be most appropriate for the nurse to make? A. "Having to urinate so often can be annoying. I suggest that you watch how much fluid you are drinking and limit it." B. "You shouldn't be urinating this frequently now; it usually stops by the time you're eight weeks pregnant. We will check your urine for glucose." C. "By the time you are 12 weeks pregnant, the frequency that you need to urinate will decrease, but it is likely to return toward the end of your pregnancy." D. "Women do not usually experience frequent urination in the first trimester. Are you experiencing any burning sensations?" C. Rationale: As the uterus grows, it presses on the urinary bladder, causing an increased frequency of urination during the first trimester. This complaint lessens during the second trimester only to reappear in the third trimester as the fetus begins to descend into the pelvis, causing pressure on the bladder. The nurse is preparing to discharge a client and her newborn after an uncomplicated delivery. Which of the following statements should be included in the discharge teaching? A. "Babies should have six or more wet diapers per day." B. "Put the baby to sleep with a blanket each night." C. "Newborn sleep-wake patterns are the same as adult sleep patterns." D. "Yellowing of the newborn's skin is a normal finding." A. Rationale: Urine and stool output are clear indicators of an infant's input and should be monitored to ensure that the baby is urinating at least six times per day. The sleep-wake cycles of an infant start opposite from adult sleep cycles and slowly shift to a daytime schedule. Babies should sleep alone in a crib or bassinet. Yellowing of the newborn's skin indicates high bilirubin levels and should be further assessed by the healthcare provider. The nurse is caring for a client who is 28 weeks pregnant. Which of the following physical changes should the nurse identify as an expected finding? A. Facial edema B. Kyphosis C. Lower extremity erythema D. Linea nigra D. Rationale: Extra integumentary pigmentation during pregnancy can create a darkened vertical line down the abdomen called linea nigra. Facial edema is an abnormal finding that requires follow-up from the healthcare provider. Lordosis is expected in pregnancy, kyphosis is not, and erythema of the lower extremities is an abnormal finding. The nurse is assessing an adolescent client for psychosocial concerns after a recent parental divorce. Which of the following statements by the client indicates that the divorce has had a negative impact on their mental health? A. "The divorce has cost my family a ton of money." B. "Living in two different houses is challenging." C. "I hope that my parents can be happy again." D. "It's my fault that they got divorced." D. Rationale: When a child voices that they feel to blame for a situation that is out of their control (such as a divorce or the death of a family member), it indicates to the nurse that the event had a significant negative impact on the child. All the other responses do not indicate a mental health concern. The nurse is teaching a parenting class to clients at a community center. Which information should be included in the education related to infant growth and development? A. "Most babies gain about 2 pounds every month until they reach 6 months old." B. "Your baby should double birth height by their first birthday." C. "Babies don't start to hold their head up until about 4 months of age." D. "You should see a doctor if your baby is not able to walk by 11 months old." A. Rationale: In the first six months of life, infants gain about 2 pounds per month; weight gain then slows to about 1 pound per month for months 6-12. Height at one year old is typically 1.5 times the infant's birth height. Infants begin holding their head up around 2 months of age, and while some infants may walk at 11 months old, it is not a cause for concern if the baby is not walking at this age. The nurse is assessing a client for barriers to learning. Which of the following statements by the client should the nurse identify as a barrier? A. "I hope you have a video for me to watch because that would be the best way for me to learn." B. "I am very excited to learn today because I want to go home so I can continue living my life." C. "How long will it take for me to learn everything I need to know to take care of myself?" D. "When can we get started because I am very anxious about everything I need to know?" D. Rationale: The nurse should recognize that pain, fatigue, depression, anxiety, or other physical or psychological symptoms can interfere with the ability to maintain attention and participate in learning. Requesting a video, expressing excitement, and willingness to care for self are all signs of motivation and readiness to learn. The nurse is screening clients at a community center for risk factors of hypertension. Which reported activity places the client at a higher risk for developing hypertension? A. Drinking 1-2 glasses of wine per week B. Traveling out of state 1 time per month C. Exercising 2-3 days per week D. Smoking 1 pack of cigarettes per day D. Rationale: Lifestyle choices that are risk factors for the development of hypertension include drinking more than one glass/day of alcohol for females and two glasses/day of alcohol for males, tobacco use, a sedentary lifestyle, and excessive dietary sodium intake often found in fast-food restaurants meals. Frequent travel has not been identified as a risk factor for the development of hypertension. During a clinic visit, a 49-year-old female client tells the nurse, "I think I am beginning to experience hot flashes." The client asks the nurse what she can do to minimize menopausal symptoms. Which of the following is an appropriate nursing response? A. "Incorporate yoga into your exercise routine." B. "Long-term use of soy supplements can help you with your symptoms." C. "Eat raw flaxseed with plenty of water." D. "Acupuncture can provide the same benefits as hormone therapy." A. Rationale: Research has shown that yoga and other meditation-based exercises can reduce the frequency and intensity of menopausal symptoms, such as hot flashes, joint pain, and mood disturbances. Long-term use of soy supplements has been associated with thickening of the lining of the uterus. There are conflicting studies on whether flaxseed is effective in lowering menopausal symptoms. Additionally, raw flaxseed can contain potentially toxic ingredients. Research has shown that acupuncture is less effective than hormone therapy. Additionally, acupuncture can cause infections and tissue damage if not performed correctly. The nurse is taking care of a client with hemiplegia due to a stroke. Which activity of daily living will the nurse encourage the client to perform? A. Brush their teeth B. Transfer from a bed to a chair C. Ambulate independently D. Tie their shoes A. Rationale: The nurse should encourage independence as much as possible. The client should be able to brush their teeth with the unaffected side. Transferring from a bed to a chair may require assistive devices due to the client's paralysis of one side of the body. Ambulating independently is not a safe activity due to hemiplegia. The client may not be able to tie their own shoes due to the paralysis of one side. The nurse is screening clients for risk factors for glaucoma. Which of the following ethnicities would have the highest risk? A. Caucasian B. Hispanic C. African American D. American Indian C. Rationale: The African American race has the highest risk for glaucoma compared to Hispanics, American Indians, and Caucasians. The nurse is assessing clients at a community center for lifestyle practices that increase the risk of cancer. Which of the following findings should the nurse identify as a significant risk? A. Exercising 30 minutes per day B. Drinking two caffeinated beverages per day C. Consuming 2000 mg of sodium each day D. Using smokeless tobacco once a day D. Rationale: Tobacco use in any form increases a client's risk for cancer significantly. Fifteen minutes of exercise and two caffeinated beverages do not increase the risk for cancer. The U.S. Department of Health recommends that a person consume less than 2300 milligrams of sodium per day, so 2000 milligrams is within these recommendations. The nurse is gathering a client's health history. Which of the following questions should be included to assess the client's lifestyle choices? A. "Do you have a family history of cardiovascular disease?" B. "How many times do you exercise per week?" C. "Does anyone in your household smoke tobacco?" D. "Are you able to perform all of your self-care independently?" B. Rationale: The nurse should ask the client questions about activity, substance use, diet, sexual health, alcohol use, etc. to assess the client's lifestyle choices. All other responses are questions about the client's health but are not lifestyle-based questions.