Test 2 - Foundations of Holistic Nursing - ATI chapters 16 - 39, FON chapters 12, 13, 14, 25, 29, 30, 33, 34, & 37 well elaborated

Test 2 - Foundations of Holistic Nursing - ATI chapters 16 - 39, FON chapters 12, 13, 14, 25, 29, 30, 33, 34, & 37 well elaborated A nurse is caring for a 19-year-old client who is sexually active and has come to the college health clinic for the first time for a checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? A. Measure the client's vital signs. B. Encourage HIV screening. C. Determine the client's risk factors. D. Instruct the client to use condoms. C A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen A A nurse at a provider's office is talking with a 45-year-old client who has no specific family history of cancer or diabetes mellitus about planning her routine screeings. Which of the following client statements indicates that the client understands how to proceed? A. "So I don't need the colon cancer procedure for another 2 or 3 years." B. "For now, I should continue to have a mammogram each year." C. "Because the doctor just did a Pap smear, I'll come back next year for another one." D. "I had my blood glucose test last year, so I won't need it again till next year." B A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. His total cholesterol result from the screening was 248 mg/dL, so he saw his provider and received a medication prescription to improve his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities of this client is an example of primary prevention? A. Cholesterol screening B. Nutrition presentation C. Medication therapy D. Cardiac rehabilitation B A nurse in a clinic is caring for a client who has multiple risk factors for cardiovascular disease. When planning health promotion and disease prevention strategies for this client, which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of her actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies. A, B, C, E When a nurse is observing a client drawing up and mixing insulin injections, which of the following best demonstrates that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique. B. The client is able to demonstrate the appropriate technique. C. The client states that he understands. D. The client is able to write the steps on a piece of paper. B A nurse in a provider's office is collecting data from the mother of a 1-year-old child. The client states that her child is old enough for toilet training. Following an educational session by the nurse, the client now states that her earlier ideas have changed. She is now willing to postpone toilet training until the child is older. Learning has occurred in which of the following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic B A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy the next day. Which of the following client statements indicates that the client is ready to learn? A. "I don't want my spouse to see my incision." B. "Will you be able to give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say." C A nurse is preparing an instructional session about managing stress incontinence for an older adult. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. Identify goals the nurse and the client agree are reasonable. D. Determine what the client knows about stress incontinence. D A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions by the nurse should assist the nurse in evaluating the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select or prepare meals. C. Encourage the client to fill out an evaluation form. D. Ask the client if she has resources for further instruction on this topic. B A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply.) A. Rolls from back to front B. Bears weight on legs C. Walks holding onto furniture D. Sits unsupported E. Sits down from a standing position A, B, D A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? A. "My baby loved to play with his crib gym, but I took it away from him." B. "I just bought a soft mattress so my baby will sleep better." C. "My baby really likes sleeping on the fluffy pillow we just got for him." D. "I just bought a child-safety gate that folds like an accordion." A A nurse is reviewing car-seat safety with parents of a 1-month-old infant. When reviewing car-seat use, which of the following instructions should the nurse include? A. Use a car seat that has a three-point harness system. B. Position the car seat so that the infant is rear-facing. C. Secure the car seat in the front passenger seat of the vehicle. D. Put soft padding in the car seat behind the infant's back and neck. B The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses by the nurse are appropriate? (Select all that apply.) A. "It might be good to add bananas, as they can help with loose stools." B. "Let's make a list of the foods he is eating so we can spot any problems." C. "Did the changes begin after you started one particular food?" D. "Has he been vomiting since he started these new foods?" E. "Most babies react with a little indigestion when you start new foods." B, C, D A parent brings a 5-month-old infant to the clinic for a well-infant check. The infant weighed 3.2 kg (7 lb) at birth. If the infant has followed the usual pattern of growth for 5 months, how much should the infant weigh? (Round the answer to the nearest tenth.) A. 13.7 lb B. 14.5 lb C. 16.3 lb D. 10.1 lb B A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply.) A. Keep toxic agents in locked cabinets. B. Keep toilet seats up. C. Turn pot handles toward the back of the stove. D. Place safety gates across stairways. E. Make sure balloons are fully inflated. A, C, D A nurse is planning diversionary activities for children on an inpatient unit. Which of the following should the nurse incorporate as appropriate play activities for a toddler? (Select all that apply.) A. Building simple models B. Working with clay C. Filling and emptying containers D. Playing with blocks E. Looking at books C, D, E A nurse is talking with the parents of toddler. Which of the following should the nurse suggest regarding discipline? A. Establish consistent boundaries. B. Place him in a room with the door closed. C. Have him learn by trial and error. D. Use favorite snacks as rewards. A A mother tells the nurse that her 2-year-old child has temper tantrums. The child says "no" every time the mother tries to help her get dressed. The nurse explains that, developmentally, the toddler is A. trying to increase her independence. B. developing a sense of trust. C. manifesting an anger management problem. D. attempting to finish a project she started. A A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parents' statements should indicate to the nurse that they understand the feeding guidelines for this age group? A. "I should keep feeding my son whole milk until he is 3 years old." B. "It's okay for me to give my son a cup of apple juice with each meal." C. "I'll give my son about 2 tablespoons of each food at mealtimes." D. "My son loves popcorn, and I know it is better for him than sweets." C A nurse is talking with the father of a 4-year-old child who states that his daughter goes to bed at 8:30 p.m. and wakes up at about 7:30 a.m., but she often lies in bed talking to herself or gets up a few times before falling asleep 40 min later. At her preschool, the children take a 2-hr afternoon nap. Which of the following recommendations should the nurse make to help improve the child's sleep behavior? A. Offer the child a snack of her favorite treat right before bedtime. B. Allow the child to watch an extra 30 min of TV in the evening. C. Change the child's bedtime to 9 p.m. on days she napped. D. Request that the preschool staff limit her nap time to 1 hr. C A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.) A. Assembling puzzles B. Pulling wheeled toys C. Using musical toys D. Using finger paints E. Coloring with crayons A, C, E A nurse is caring for a 5-year-old client whose parents report that she fears painful procedures, such as injections. Which of the following strategies should the nurse use to try to help ease the child's fear? (Select all that apply.) A. Invite the child to assist with mealtime activities. B. Cluster invasive procedures whenever possible. C. Assign caregivers with whom the child is familiar. D. Have the parents bring in a favorite toy from home. E. Engage the child in pretend play with a toy medical kit. A, D, E A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of two preschoolers. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type b B. Varicella C. Polio D. Hepatitis A E. Seasonal influenza B, C, E A nurse is talking with parents of a preschooler who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? A. "Our son will only eat a few things, like burgers and bananas, and pretty much refuses everything else." B. "Our son has these temper tantrums every time we tell him to do something he doesn't want to do." C. "We think our son truly believes that his toys have personalities and talk to him, especially at night." D. "We feel bad when we see our son trying so hard to button his shirt. We just tell him this is something he'll just have to learn to do." B A nurse is talking with parents of a school-age child who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? A. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping." B. "Our son keeps trying to find ways around our household rules. He always wants to make deals with us." C. "We think our son is trying too hard to excel in math just to get the top grades in his class." D. "Our son is always afraid the kids in school will laugh at him because he likes to sing and write little poems." A A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for school-age children? (Select all that apply.) A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Shaping modeling clay A, B, C A nurse is reviewing nutritional guidelines with the parents of an 11-year-old child. Which of the following parents' statements should indicate to the nurse that they understand the guidelines for school‑age children? A. "She wants to eat as much as we do, but we're afraid she'll soon be overweight." B. "She skips lunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner." C. "We limit fast-food restaurant meals to three times a week now." D. "We reward her school achievements with a point system instead of a pizza or ice cream." D A nurse is talking with the parents of a 10-year-old child who express concern that their son is suddenly becoming secretive, for example, closing the door when he showers, dresses, and does his homework in his room. Which of the following responses by the nurse is appropriate? A. "Perhaps you should try to find out what he is doing behind those closed doors." B. "Suggest that he leave the door ajar for his own safety." C. "At this age, children tend to become more modest and value their privacy." D. "Tell him it's okay to close the door when he is undressed, but he has to do his homework where you can see him." C A nurse at an elementary school is planning a health promotion and primary prevention class. Which of the following topics are appropriate to include for the parents of school-age children? (Select all that apply.) A. Childhood obesity B. Substance use disorders C. Scoliosis screening D. Front-seat seatbelt use E. Stranger awareness A, B, C, E A nurse is talking with the father of a 12-year-old boy who is concerned that he hasn't observed any indications that his son is approaching puberty. The nurse should explain that the first sign of sexual maturation in boys is A. the appearance of downy hair on the upper lip. B. hair growth in the axillae. C. enlargement of the testes and the scrotum. D. deepening of the voice. C A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions are appropriate for this client? (Select all that apply.) A. Suggest that his parents room in with him. B. Provide a television and DVDs for him to watch. C. Limit visitors to immediate family. D. Devise a regular schedule for inpatient routines. E. Allow him to perform his own morning care. B, E A nurse is talking with an adolescent who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I kind of like this girl in my class. She doesn't like me back, though, not that way." B. "I like hanging out with the guys in the science club, but the jocks pick on them." C. "I just don't seem to be any good at anything. I can't play any sports at all." D. "My dad wants me to be a lawyer like him, but I don't want to learn all that stuff." C A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza B, D, E A nurse is preparing a wellness presentation for families at a community center. When discussing health screenings for adolescents, which of the following information about scoliosis should the nurse include? (Select all that apply.) A. Scoliosis is more common among girls than it is among boys. B. Loss of height is often the first sign of scoliosis. C. Scoliosis screening is essential during the adolescent growth spurt. D. Slouching is a common cause of scoliosis, especially in adolescents. E. Scoliosis is a forward curvature of the spine. A, C A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "If I am having any discomfort, I'll just go to an urgent care center." D. "If I am feeling stressed, I will remind myself that this is something I should expect." B A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between and being responsible for two generations C A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My girlfriend is pregnant, and I don't think I have what it takes to be a good father." C A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home. B, C, D A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio A, B, C A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of accomplishing Erikson's tasks for psychosocial development during middle adulthood? A. The client evaluates his behavior after a social interaction. B. The client states he is learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation. D A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following capabilities? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Feel frustrated that time is too short for attempting to start another life. C. Welcome opportunities to be creative and productive. D. Commit to finding friendship and companionship. E. Become involved with community issues and activities. C, E A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretion D. Far vision E. Glomerular filtration A, C, E A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a middle adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type b B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza B, C, E A nurse is counseling a middle adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my son expects me to relive my parenting days." B A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority for further assessment and intervention? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my son to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I'm struggling with helping out in my community. I just don't know what I can do." D A nurse is admitting an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following questions should the nurse ask to investigate the source of his weight loss? (Select all that apply.) A. "Do you eat alone or with someone?" B. "Do you watch television while eating your meals?" C. "Have you started any new medications in the past 6 months?" D. "What foods have you eaten within the past 24 hours?" E. "Are you on a fixed income?" A, C, D, E A nurse is planning a presentation to a group of older adults at a senior community center about the essential screening tests and preventive procedures during this stage of life. Which of the following should the nurse include? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Eye examination D. Mental health screening E. Dual-energy x-ray absorptiometry (DEXA) scanning B, C, D, E A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase iron intake to prevent anemia. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation. C, D, E A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity B, D, E A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3° C (101° F), a pulse rate of 114/min, and a respiratory rate of 22/min. He is restless and his skin is warm. Which of the following are appropriate nursing interventions for this client? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to limit activity and rest. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently. A, C, E A nurse is instructing an assistive personnel (AP) in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting her respirations." D. "Let the client rest for 5 minutes before you measure her blood pressure." A A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-Fowler's position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 1 min if it is regular. E. Count and report any sighs the client demonstrates. A, B, C A nurse who is admitting a client who has a fractured femur obtains a blood pressure (BP) reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive medication. B. Ask the client if she is having pain. C. Request a prescription for an anti-anxiety medication. D. Return in 30 min to recheck the client's BP. B A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min and her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? A. 15/min. B. 16/min. C. 17/min. D. 18/min. B A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch." A, C, E A client asks the nurse what her Snellen eye test results mean. Her visual acuity is 20/30. Which of the following responses is appropriate? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 ft what visually unimpaired eyes see at 20 ft." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet." A A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension of the trachea on both sides of the midline A, D, E A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions are appropriate? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape. B, D, E A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums C, D, E A nurse in a provider's office is preparing to perform a breast examination for an older adult who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion A, D, E A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds C, D, E During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias C During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur B, D A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits A, B A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill in 2 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the face A, D, E A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (Select all that apply.) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive dryness and wrinkling B, C, D A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system? (Select all that apply.) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature B, C, E A nurse is reviewing the various types of lesions nursing students might encounter when performing integumentary assessments for their clients. Which of the following lesions should the nursing students recognize as vesicles? (Select all that apply.) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella D, E