Health Promotion and Maintenance PDF

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A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure? Rationale: The normal reference range for the glycosylated hemoglobin A1c (HgbA1c) is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Therefore, an HgbA1c of 9% is elevated. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

4.

Preventing and recognizing hyperglycemia

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. Rationale: A focused data collection process is centered around a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

1.

Listening to lung sounds

2.

Obtaining the client's temperature

4.

Obtaining information about the client's respirations

The nurse is reinforcing instructions for a client in how to perform a testicular selfexamination (TSE). Which instructions should the nurse include? Select all that apply. Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. This will provide ease in palpating, and the client will be better able to identify any abnormalities. The nurse should instruct the client to select a day of the month and perform the examination on the same day each month to avoid forgetting to do the examination. TSE is done by the client rolling each testicle between the thumb and fingers. The client should seek medical attention if a lump, mass, or swelling of the testicle is detected. The bladder does not have to be empty to complete the examination. There is no connection between urethral discharge and TSE.

1.

Perform TSE after a shower or bath.

3.

Perform TSE on the same day each month.

5.

Perform TSE by rolling each testicle between the thumb and fingers.

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory? Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal morality. The other options are correct statements regarding Kohlberg's theory.

1.

"Individuals move through all six stages in a sequential fashion."

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response? Rationale: According to Erikson, at ages 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents. Therefore, the other options identify incorrect responses.

4.

"At this age, the child is developing his or her own personality."

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents? Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, the infant will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others. Therefore, the remaining options are incorrect.

1.

Allow the infant to signal a need.

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent? Rationale: According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents" wishes. Saying things like "no" and "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Punishing the child every time the child says "no" is likely to produce a negative response.

1.

Set limits on the child's behavior.

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement?

Rationale: In the preoperational stage, the child is demonstrating egocentric thinking by believing the moon's actions revolve around the child. In the sensorimotor stage, a child does not believe an object exists if it is not in sight. A child in the concrete operations stage is able to classify, order, and sort facts, such as the multiplication tables. A child in the formal operations stage is able to solve more complex problems, such as using a map to determine location and directions.

4.

"The moon follows me, and goes to bed when I go to bed".

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage? Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces. Self-gratification relates to the oral stage. Tapering off of conscious biological and sexual urges relates to the latency period. Association with pleasurable and conflicting feelings about genital organs relates to the phallic stage.

2.

Beginning of toilet training

When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply. Rationale: Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

2.

Decline in visual acuity

5.

Increased susceptibility to urinary tract infections

6.

Increased incidence of awakening after sleep onset

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance? Rationale: Exercise and activity are essential for health promotion and maintenance in the older adult and for achieving an optimal level of functioning. One of the best exercises for an older adult is walking, with the goal of progressing to 30-minute sessions three to five times each week. Gardening for an hour each day may not be practical. Not all clients have access to sculpting, and performing the activity once a week for 40 minutes would not provide enough activity. Cycling three times a week for 20 minutes would not provide enough activity, and not all clients have access to cycling.

4.

Walking three to five times a week for 30 minutes

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate? Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.

2.

"Do you plan to have any other children?"

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date? Rationale: The accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. In this case, the first day of the LMP was October 20, 2019. When you subtract 3 months, you get July 20, 2019. If you add 7 days, you get July 27, 2019. Add 1 year to this, and you get the estimated date of birth: July 27, 2020.

2.

July 27, 2020

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? Rationale: Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity. Options 1, 2, and 3 are incorrect; these gestational time frames are too early for quickening.

4.

16 and 20 weeks' gestation

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client? Rationale: Pregnancy outcomes can be described with the GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/miscarriages (number of abortions/miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.

2.

G = 2, T = 1, P = 0, A = 0, L = 1

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy? Rationale: During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination. Goodell's sign does not indicate the presence of fetal movement. Human chorionic gonadotropin is noted in maternal urine with a positive urine pregnancy test. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; it is the result of blood circulating through the placenta.

1.

A softening of the cervix

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding? Rationale: During the second and third trimesters (18–30 weeks' gestation), the fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 cm. In addition, at this point in the pregnancy, in a 4 week period, the fundal height should increase approximately 4 cm. At 14 to 16 weeks' gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and at term, the fundus is at the xiphoid process.

2.

26 cm

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? Rationale: Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions.

3.

Tell the client that these are common and they may occur throughout the pregnancy.

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply. Rationale: The probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy); Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's fingers on palpation); Braxton Hicks contractions; and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a

nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound.

1.

Ballottement

2.

Chadwick's sign

3.

Uterine enlargement

4.

Braxton Hicks contractions

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term? Rationale: Quickening is fetal movement that appears usually at weeks 16 to 20, when the expectant mother first notices subtle fetal movements that gradually increase in intensity. A compressibility of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; this is known as uterine souffle. This sound is the result of blood circulation to the placenta, and it corresponds with the maternal pulse.

1.

"It is the fetal movement that is felt by the mother."

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure? Rationale: Leg cramps often occur when the pregnant woman stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping. Therefore, the remaining options are incorrect.

3.

Dorsiflex the client's foot while extending the knee.

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure? Rationale: Caffeine, like spices, may cause heartburn and needs to be avoided. Spices tend to trigger heartburn. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.

2.

Drink decaffeinated coffee and tea.

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? Rationale: Amenorrhea may occur during breastfeeding, but the client can still ovulate without menstruating. The caloric intake should be increased by 200 to 500 cal/day (per PHCP's prescription), and the diet should include additional fluids and prenatal vitamins, as

prescribed. The use of soap on the breasts is avoided because it tends to remove natural oils, which can lead to cracked nipples. 1.

"I don't need birth control because I will be breastfeeding."

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? Rationale: Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately 1 fingerbreadth or 1 cm per day. The other options do not accurately describe involution.

4.

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and well-fitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding.

4.

Massage the breasts before feeding to stimulate let-down.

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? Rationale: Bathing should start at the eyes and face, which are usually the cleanest areas. Next, the external portion of the ears and behind the ears are cleansed. The newborn's neck should be washed, because formula, breast milk, or lint will often accumulate in the folds of the neck. The hands and arms are then washed. The baby's legs are washed, with the diaper area being washed last.

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