Practice Assessment: 2019 RN VATI
Health Promo/Maintenance - End of
Review
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a
local health fair. Which of the following instructions should the nurse include? - ANS -Breasts
can be examined in the shower with soapy hands.
The nurse should encourage clients to perform a BSE or do an extra examination while
showering. This allows clients to concentrate more easily on feeling for tissue changes.
The nurse should instruct clients to report breast dimpling or discharge. Changes in the texture
of breast tissue are associated with menses, menopause, hormone replacement therapy, and
pregnancy.
The nurse should instruct clients who have a menstrual cycle to perform a BSE every month,
about 7 days after menstruation ends.
The nurse should instruct clients to use the sensitive finger pads of the middle three fingers to
perform a BSE.
\A home health nurse is teaching a client who is breastfeeding about managing breast
engorgement. Which of the following client statements indicates understanding of the teaching?
- ANS -"I'll feed my baby every 2 hours."
Breast engorgement is relieved by emptying both breasts. The client might be able to
accomplish this with more frequent feedings. Otherwise, she can pump her breasts after
breastfeeding to ensure optimal emptying.
\A nurse is assessing a toddler at a well-child visit. At what point in the physical examination
should the nurse examine the child's tympanic membrane? - ANS -At the end.
When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at
the head but deferring anything that the toddler is likely to view as invasive and traumatic to the
very end. The toddler is likely to resist not only having the ears examined, but also anything that
follows.
\A nurse is assessing a toddler who has heart failure. Which of the following findings should the
nurse expect? - ANS -Orthopnea
A toddler who has heart failure has increased venous return to the heart and lungs, which leads
to pulmonary congestion. The congestion causes orthopnea, or difficulty breathing, while lying
, down. Having the toddler sit up decreases venous return, as well as pressure the abdominal
organs have on the diaphragm. This decrease in pressure improves breathing and oxygenatio
\A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with
contact precautions in place. Which of the following toys should the nurse recommend in order
to meet the developmental needs of the client? - ANS -Large building blocks
Large building blocks are age-appropriate toys for a 12-month-old toddler.
\A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is
distressed after an insulin injection. Which of the following play activities should the nurse
recognize is therapeutic in helping the child deal with the injection? - ANS -A needleless syringe
and a doll
Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child,
because they will allow the child to act out feelings of anger and helplessness.
\A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the
parents visit the next day, the nurse explains the situation and one of the parents says, "She
never wets the bed at home. I am so embarrassed." Which of the following responses should
the nurse make? - ANS -"It is expected for children who are hospitalized to regress. The
toileting skills will return when your child is feeling better."
A recently learned skill, such as toilet training, is often temporarily lost due to the stress of
hospitalization. The nurse should reassure the parents that regression is an expected behavior
in children who are hospitalized and that her child will regain bladder control when she is feeling
better.
\A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client
about common discomforts in the first trimester of pregnancy as well as warning signs of
potential danger. The nurse should instruct the client to call the clinic if she experiences which of
the following manifestations? - ANS -Facial edema
Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be
reported immediately to the provider.
\A nurse is caring for a client who has diverticular disease. When palpating the client's
abdomen, in which of the following locations should the nurse expect the client to report
abdominal pain? - ANS -Lower left quadrant
The nurse should expect the client to have abdominal pain in the lower left quadrant of the
abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal
contents from the rectum causes pouch formation.
\A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she
can continue to exercise during pregnancy. Which of the following responses by the nurse is
appropriate? - ANS -"Daily jogging for up to 30 minutes is fine throughout the pregnancy."
Health Promo/Maintenance - End of
Review
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a
local health fair. Which of the following instructions should the nurse include? - ANS -Breasts
can be examined in the shower with soapy hands.
The nurse should encourage clients to perform a BSE or do an extra examination while
showering. This allows clients to concentrate more easily on feeling for tissue changes.
The nurse should instruct clients to report breast dimpling or discharge. Changes in the texture
of breast tissue are associated with menses, menopause, hormone replacement therapy, and
pregnancy.
The nurse should instruct clients who have a menstrual cycle to perform a BSE every month,
about 7 days after menstruation ends.
The nurse should instruct clients to use the sensitive finger pads of the middle three fingers to
perform a BSE.
\A home health nurse is teaching a client who is breastfeeding about managing breast
engorgement. Which of the following client statements indicates understanding of the teaching?
- ANS -"I'll feed my baby every 2 hours."
Breast engorgement is relieved by emptying both breasts. The client might be able to
accomplish this with more frequent feedings. Otherwise, she can pump her breasts after
breastfeeding to ensure optimal emptying.
\A nurse is assessing a toddler at a well-child visit. At what point in the physical examination
should the nurse examine the child's tympanic membrane? - ANS -At the end.
When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at
the head but deferring anything that the toddler is likely to view as invasive and traumatic to the
very end. The toddler is likely to resist not only having the ears examined, but also anything that
follows.
\A nurse is assessing a toddler who has heart failure. Which of the following findings should the
nurse expect? - ANS -Orthopnea
A toddler who has heart failure has increased venous return to the heart and lungs, which leads
to pulmonary congestion. The congestion causes orthopnea, or difficulty breathing, while lying
, down. Having the toddler sit up decreases venous return, as well as pressure the abdominal
organs have on the diaphragm. This decrease in pressure improves breathing and oxygenatio
\A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with
contact precautions in place. Which of the following toys should the nurse recommend in order
to meet the developmental needs of the client? - ANS -Large building blocks
Large building blocks are age-appropriate toys for a 12-month-old toddler.
\A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is
distressed after an insulin injection. Which of the following play activities should the nurse
recognize is therapeutic in helping the child deal with the injection? - ANS -A needleless syringe
and a doll
Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child,
because they will allow the child to act out feelings of anger and helplessness.
\A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the
parents visit the next day, the nurse explains the situation and one of the parents says, "She
never wets the bed at home. I am so embarrassed." Which of the following responses should
the nurse make? - ANS -"It is expected for children who are hospitalized to regress. The
toileting skills will return when your child is feeling better."
A recently learned skill, such as toilet training, is often temporarily lost due to the stress of
hospitalization. The nurse should reassure the parents that regression is an expected behavior
in children who are hospitalized and that her child will regain bladder control when she is feeling
better.
\A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client
about common discomforts in the first trimester of pregnancy as well as warning signs of
potential danger. The nurse should instruct the client to call the clinic if she experiences which of
the following manifestations? - ANS -Facial edema
Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be
reported immediately to the provider.
\A nurse is caring for a client who has diverticular disease. When palpating the client's
abdomen, in which of the following locations should the nurse expect the client to report
abdominal pain? - ANS -Lower left quadrant
The nurse should expect the client to have abdominal pain in the lower left quadrant of the
abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal
contents from the rectum causes pouch formation.
\A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she
can continue to exercise during pregnancy. Which of the following responses by the nurse is
appropriate? - ANS -"Daily jogging for up to 30 minutes is fine throughout the pregnancy."
