ASSESSMENTS ACTUAL EXAM
STUDY GUIDE. GRADED A+.
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A pregnant client has a history of giving birth to one set of twin boys, one term
girl and 2 early spontaneous abortions. What is her gravida and para? -
Ans✔✔-She is gravida 4, Para 2
Gravida indicates the number of times the mother has been pregnant,
regardless of whether these pregnancies were carried to term. A current
pregnancy, if any, is included in this count.
Para indicates the number of >20 wks births (including viable and non-viable
i.e. stillbirths). Pregnancies consisting of multiples, such as twins or triplets,
count as ONE birth for the purpose of this notation.
A nurse is providing care for an uncircumcised male newborn and his mother.
What information should be provided during discharge regarding bathing of
the penile area of the newborn male? - Ans✔✔-To cleanse an uncircumcised
penis, wash with soap and water and rinse the penis. The foreskin should not
be forced back or constriction may result.
,The 24-year-old client inquires about use of the diaphragm for birth control.
What five (5) instructions would be provided by the nurse to explain use of the
diaphragm? - Ans✔✔-●A client should be properly fitted with a diaphragm by a
provider.
●Replaced every 2 years and refitted for a 20% weight fluctuation, after
abdominal or pelvic surgery, and after every pregnancy.
●Requires proper insertion and removal. Prior to coitus, the diaphragm is
inserted vaginally over the cervix with spermicidal jelly or cream that is applied
to the cervical side of the dome and around the rim. The diaphragm can be
inserted up to 6 hr before intercourse and must stay in place 6 hr after
intercourse but for no more than 24 hr.
●Spermicide must be reapplied with each act of coitus.
●A client should empty her bladder prior to insertion of the diaphragm.
●Diaphragm should be washed with mild soap and warm water after each use.
A nurse is providing teaching about fibrocystic breast tissue with a client. What
information will the nurse share with the client about diagnostics used to
confirm the diagnosis? - Ans✔✔-Diagnostics for fibrocystic breast tissue
include breast ultrasound and fine-needle aspiration.
A client asks the nurse how often she should get a Papanicolaou (Pap) test.
What is the correct response by the nurse to the client? - Ans✔✔-21: All
women begin screening for cervical cancer
21-29: Pap test every 3 years; HPV unnecessary unless needed following an
abnormalPap test
30-65: Pap and HPV every 5 years
Older than 65: May discontinue testing if regular screenings have been
negative; If diagnosed with cervical precancer, continue to screen
, List three (3) actions by the nurse should take during the assessment and data
collection steps. - Ans✔✔-Recognize patterns or trends.
Compare the data with expected standards or reference ranges.
Arrive at conclusions to guide nursing care.
When witnessing an informed consent the nurse must ensure that the provider
gives the client the necessary procedural information. Identify information the
provider should disclose to the client to obtain an informed consent. What is
the role of the nurse in this process? - Ans✔✔-The Provider obtains the
informed consent. To do so, the provider must give the client:
· The purpose of the procedure· A complete description of the procedure.
· A description of the professional who will perform and participate in the
procedure.
· A description of the potential harm, pain or discomfort that might occur.
· Options for other treatments.
· The option to refuse treatment and the consequences of doing so. The nurse
must notify the provider if the client has more questions or appears not to
understand any of the information. The provider is then responsible for giving
clarification.
Discuss passive and active immunity. - Ans✔✔-Passive: Antibodies are
produced by an external source. Temporary immunity that does not have
memory of past exposures. Intact skin, the body's first line of defense. Mucous
membranes, secretions, enzymes, phagocytic cells, and protective proteins.
Inflammatory response with phagocytic cells, the complement system, and
interferons to localize the invasion and prevent its spreadActive: Antibodies are
produced in response to an antigen. Requires time to react to antigens.
Provides permanent immunity. Involves B- and T-lymphocytes. Produces