NUR 304 Exam 4 | Answered with Rationales (Complete Solutions)

NUR 304 Exam 4 | Answered with Rationales (Complete Solutions) A 6-week-old infant grasps a rattle placed in the hand. The parent is impressed with this skill. What should the nurse teach the parent about this behavior ...

NUR 304 Exam 4 | Answered with Rationales (Complete Solutions) A 6-week-old infant grasps a rattle placed in the hand. The parent is impressed with this skill. What should the nurse teach the parent about this behavior? 1 This is the palmar grasp reflex and is expected at this age. 2 This is the pincer grasp, which disappears within several months. 3 Grasping is a voluntary behavior usually observed in older infants. 4 Grasping is an atypical behavior, and further evaluation is required. The palmar grasp reflex is expected at 6 weeks of age, begins to fade at 2 months, and disappears by 4 months. The pincer grasp is a fine motor voluntary behavior that begins around 8 months of age. Grasping is involuntary behavior; it is a reflex response that is not expected in older infants. The palmar grasp reflex is typical, not atypical, for a 6-week-old infant. Place the order of blood flow from right side of heart to pulse oximetry measurement. ORDER: a. O2 blood flow pumps from left side of heart to peripheral arteries b. Deoxygenated blood flows to pulmonary capillaries c. Hemoglobin saturated w/ O2 flows to pulmonary veins d. O2 diffuses from alveoli to blood b. Deoxygenated blood flows to pulmonary capillaries d. O2 diffuses from alveoli to blood c. Hemoglobin saturated w/ O2 flows to pulmonary veins a. O2 blood flow pumps from left side of heart to peripheral art The parents of a 6-month-old ask a nurse how to introduce their infant to pureed foods. How should the nurse respond? 1 "Introduce one food at a time every 4 to 7 days." 2 "Mix the pureed food with the formula two or three times a day." 3 "Try to maintain the formula intake regardless of solid food intake." 4 "Offer pureed foods by spoon after the bottle of formula is finished." The introduction of one new food at a time permits the identification of any food allergies that might be present; intake of multiple new foods makes identification of the causative foods more difficult if there is a reaction. Mixing the food with formula can create feeding problems; if the infant does not like the taste of a food, it may be associated with the formula. Formula intake should be decreased as solid food intake increases, or the infant will be receiving excessive calories. Although pureed foods may be offered by spoon once the formula is finished, solid foods should be given when the infant is hungry to encourage intake. A client in her 37th week of gestation calls the nurse at the clinic and reports, "My ankles are so swollen." Which intervention should the nurse recommend? 1 Limiting fluid intake during the day 2 Elevating her legs more frequently during the day 3 Restricting salt intake for the remainder of her pregnancy 4 Taking a mild diuretic that the healthcare provider will prescribe Dependent edema in the ankles is a common occurrence during the latter part of pregnancy. It results from increased pressure of the uterus on the pelvic veins. Elevating the legs encourages venous return. Limiting fluid intake can be harmful; increased circulating blood volume during pregnancy must be maintained. Salt is necessary to retain fluid for the increased circulating blood volume during pregnancy. Diuretics are not utilized during pregnancy; they may decrease the circulating blood volume. When does the anterior fontanel of an infant close? 1 At 4 to 10 months 2 At 8 to 12 months 3 At 12 to 18 months 4 At 18 to 26 months The anterior fontanel usually closes between 12 and 18 months. The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? 1 Low birthweight 2 Facial abnormalities 3 Chronic lung problems 4 Hyperglycemic reactions Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia. While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? 1 Recording these expected findings 2 Obtaining an order for an oxytocic medication 3 Asking the client when she last changed the perineal pad 4 Notifying the primary healthcare provider that the client may be hemorrhaging The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported or recorded without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion. For which client(s) should the nurse consider family members as the primary source of information? Select all that apply. 1 Older adult 2 Infant or child 3 During traumatic emergency 4 When critically ill, disoriented 5 In an outpatient clinic visit The nurse interviews the parents who care for the infant or child. Thus, the parents become the primary source of information. A client who is brought to the emergency department after a trauma may not be in a position to explain the circumstances that led to the visit. In this case, the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The older adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment. Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? 1 Attention span 2 Primary language 3 Coping mechanisms 4 Activity and coordination Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination. A nurse is assessing growth and development in a 6-month-old infant. What behaviors does the nurse expect the infant to demonstrate? 1 Sitting alone, displaying pincer grasp, and waving bye-bye 2 Pulling up to a standing position, releasing a toy by choice, and playing peek-a-boo 3 Crawling, transferring a toy from one hand to the other, and displaying fear of strangers 4 Turning over completely, sitting momentarily without support, and reaching to be picked up Turning over completely, sitting momentarily without support, and reaching to be picked up are age appropriate actions in 6-month-old infants. The ability to sit alone, display a pincer grasp, and wave bye-bye; pull up to a standing position, release a toy by choice, and play peek-a-boo; and crawl, transfer a toy from hand to hand, and display fear of strangers should have developed by 10 months of age. The clinic nurse is teaching an adolescent about lifestyle modifications to prevent hyperlipidemia. Which statement by the adolescent indicates a need for further teaching? 1 "I'll start eating more red meat." 2 "I'm going to eat a lot of low-fat yogurt." 3 "I'll try to stop eating so much processed food." 4 "I'll start eating whole-grain bread instead of white." Red meats are high in fat. The monounsaturated and polyunsaturated fats can increase high density lipoprotein and decrease low density lipoprotein cholesterol. For this reason, an increase in the consumption of red meat is not advisable. Most whole grains, breads, pastas, and cereals are naturally low in fat. Adolescents should be taught to choose lean meats, beans, and low-fat dairy products and to limit their intake of processed foods such as crackers, cookies, cakes, and higher fat snacks. A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections? 1 "Wear cotton underpants." 2 "Void at least every 6 hours." 3 "Increase foods containing alkaline ash in the diet." 4 "Wipe from back to front after toileting." Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments. Voiding frequently helps to flush ascending microorganisms from the bladder, thereby reducing the risk for urinary tract infections; holding urine for 6 hours can lead to urinary tract infections. Foods high in acid, not alkaline, ash help to acidify urine; this urine is less likely to support bacterial growth. Alkaline urine promotes bacterial growth. Wiping from back to front after toileting may transfer bacteria from the perianal area toward the urinary meatus, which will increase the risk for urinary tract infection. Which event is considered as the hallmark of late puberty in young girls? 1 Breast enlargement 2 Adult type sexual hair 3 First menstrual period 4 Physiologic leukorrhea First menstrual period is considered the hallmark of late puberty in young girls. Breast enlargement along with change in pubic hair to adult type sexual hair covering the mons pubis and labia majora occurs during mid-puberty stage. Physiologic leukorrhea (increased normal vaginal discharge) marks the uterine development early in puberty. A nurse is presenting a program to new mothers about back to sleep initiative to prevent babies choking while sleeping and CPR. Which level of prevention is nursing practicing? primary prevention secondary prevention tertiary prevention quaternary prevention secondary means at risk of disease tertiary (person actively in rehab program as example) A nurse is presenting a program to workers in a factory covering safety topics including wearing hearing protectors while working in the factory. Which level of prevention is the nurse practicing? primary prevention secondary prevention tertiary prevention quaternary prevention secondary prevention means they already have it A nurse is showing a patient newly diagnosed with type II DM how to use a glucometer and make a daily journal of his glucose values for his next doctor visit. which level of prevention is the nurse practicing? primary prevention secondary prevention tertiary prevention quaternary prevention A patient registered at a local fitness center and purchased a pair of exercise shoes. The patient is in what stage of behavior change? Pre-contemplation contemplation Preparation Action A patient has surgery for a fractured wrist due to a motor vehicle accident and is currently participating in a daily rehab session. At the surgeon's office, which level of prevention is this patient practicing? primary prevention secondary prevention tertiary prevention quaternary prevention The patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C measurement over past 90 days has increased. The patient states that his hemoglobin A1C is wrong, "my blood sugar levels have been excellent for the last 6 months". Which defense mechanism is the patient using? A. Denial. B. Conversion. C. Dissociation. D. Displacement. Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient's statements reflect denial about poorly controlled blood sugars. A grandfather living in Japan worries about his two young grandsons who disappear after the tsunami. This is an example of which crisis? situational crisis matritional crisis maturational crisis adventitious crisis developmental crisis adventitious= social crisis or natural disaster situational= accident or death When assessing an older adult who is showing sx of anxiety, insomnia, anorexia, malconfusion, one of the FIRST assessments includes which of the following? The amount of family support A 3-day diet recall A thorough physical assessment Threats to safety in her home A 72 year old patient asks the nurse about using an over the counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? a. Antihistamines are better than prescription medications because these can cause a lot of problems b. Antihistamines should not be used because they can cause confusion and increase your risk of falls c. Antihistamines are effect sleep aids because they do not have many side effects d. Over the counter medications when combined with sleep-hygiene measures are a good plan for sleep Older adults should avoid the use of over the counter antihistamines. These medications have a long duration of action in older adults and can cause confusion, constipation, urinary retention, and increased risk of falls. The patient reports episodes of sleepwalking to the nurse. Through understanding of the sleep cycle, the nurse recognizes that sleepwalking occurs during which sleep phase? a. Rapid Eye Movement (REM) Sleep b. Stage 1 non-rapid eye movement (NREM) sleep c. Stage 4 NREM sleep d. Transition period from NREM to REM sleep Stage 4 NREM sleep is the deepest stage of sleep. It is difficult to rouse the sleeper in this stage. During this stage sleepwalking and enuresis (bed-wetting) sometimes occur A nurse incorporates which priority nursing intervention into a plan of care for sleep for a hospitalized patient? a. have patient follow hospital routines b. avoid waking patient for nonessential tasks c. give prescribed sleeping medications at dinner d. turn tv on low to late-night programming A nurse is preparing to perform a cultural assessment of a patient. Which of the following questions is an example of a contrast question? 1. Tell me about your ethnic background 2. Have you had this problem in the past? 3. Where do other members of your family live? 4. How different is this problem from the one you had previously? With the exception of pregnant or lactating women, the young adult has usually completed physical growth by the age of: 1 18. 2 20. 3 25. 4 30. A nurse is preparing to make a mandatory report of intimate partner violence (IPV) with regard to the caregiver of a pediatric client. Which actions are appropriate? (Select all that apply.) A) Tell the child about the possibility of filing a mandatory report B) Determine whether it will be safe to inform the child about the report C) Ask about the child's incidence of using drugs D) Ask the victim whether she has a plan to keep herself and the child safe E) Ask the victim if she would like to file a report at the same time as you file yours Feedback: The nurse should take the following actions when making a mandatory report of IPV: (1) Talk with the adult victim (not the child) about the possibility of filing a mandatory report. (2) Consider the safety concerns of filing. (3) Determine whether it will be safe to inform the children about the report. (4) Share concerns of safety with the Child Protective Agency. (5) Ask about the perpetrator's behaviors with questions such as the following: What is the worst thing he or she has done? Does he or she own a gun? Has he or she been arrested? Does he or she use drugs (not does the child use drugs)? Do you think he or she is capable of hurting you or your children? (6) Address safety planning with the nonoffending victim. (7) Consider filing in concert with the adult victim. Intimate partner violence is linked to which of the following factors. Select all that apply. alcohol abuse marriage pregnancy unemployment drug use Middle-age adults frequently find themselves trying to balance responsibilities related to employment, family life, care of children, and care of aging parents. People finding themselves in this situation are frequently referred to as being a part of: 1 The sandwich generation. 2 The millennial generation. 3 Generation X. 4 Generation Y. A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room 2. Adequate staffing is available for all residents 3. Social activities are available for all residents 4. The center provides three meals daily with a set menu and serving schedule 5. Staff encourage family involvement in care planning and assisting with physical care The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the A.Patient's individual cultural beliefs B.Values of her own culture C.Spanish speaking community D.Work history Obtaining information about the patient's cultural beliefs will help the nurse provide care tailored to the patient's needs. The nurse realizes that the primary goal of a cultural assessment is to: A.Minimize client distress resulting from unmet cultural expectations B.Identify care that complements the client's cultural expectations C.Identify cultural beliefs and traditions that are important to the nurse. D.Blend Western nursing practice with the client's cultural expectations Identify care that complements the clients cultural expectations may help the nurse complete a cultural assessment for the patient To determine how the client, who is a single parent of three children, will be able to cope with the current pregnancy, the nurse should ask the client: A."Have you ever been married?" B."Where do you currently work?" C.Has anyone ever taught you about contraception?" D."Who do you have for support during this pregnancy?" The nurse should ask the client, "Who do you have for support during this pregnancy" to determine how the client will be able to cope with the current pregnancy. Which statement best describes the health-illness continuum? A.Health is the absence of disease; illness is the presence of disease. B.Health and illness are along a continuum that cannot be divided. C.Health is remission of disease; illness is exacerbation of disease. D.Health is not having illness; illness is not having health. Which of the following ways can nurses promote health? A.Prescribing medications B.Telephone counseling C.Scolding patients when non-compliant D.Interpreting diagnostic exams The comment "All Accelerated Option Nursing Students are overachievers" can be considered: A.A bias B.An archetype C.A stereotype D.Discrimination At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful? A.Normalization of blood pressure B.Decreased peripheral skin temperature C.Increased heart rate D.Increased blood pressure A cancer patent incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner? A.Acupuncture B.Yoga C.Reiki D.Biofeedback According to the stages of development, an 85 year old patient may have difficulty with: A.Learning to tie his shoes B.Finding meaningful work C.Achieving personal gains D.Activities of daily living As a child, a young woman was told repeatedly she was "stupid". As an adult, she excels as a nurse and attains her Doctorate of Nursing Practice. This response can be viewed as which of the following adaptive mechanisms? A.Projection B.Compensation C.Sublimation D.Displacement Which statement by the nurse is best when communicating with a patient with clinical depression? A."It's a beautiful day today; you'll feel better if you look out the window." B."You're having a bad day; I'm sure you'll feel better soon." C."Life seems overwhelming at times; would you like to discuss how you're feeling?" D."You are very lucky to have such a supportive family." Which of the following patients are involved in the tertiary level of prevention? Pick all that apply. A.A 55 year old male who is rehabilitating from a stroke B.A 15 year old female receiving the Human Papillomavirus vaccine C.An overweight patient participating in a weight loss program D.A diabetic patient who is learning how to self-administer insulin injections E.A 45 year old female who is scheduled for a mammogram Remember as part of tertiary prevention, the patient already has the disease or problem and making corrective actions to prevent further problems or to return to a healthy state. Care that encompasses conventional medicine and complementary therapies is considered: A.Alternative B.Conventional C.Holistic D.Integrative A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: A. living wills. B. assisted suicide. C. passive euthanasia. D. advance directives. •Rationale: Advance directives are written documents that outlay the patient's wishes, should he or she become incapacitated. A student nurse employed as a nursing assistant may perform care: A. as learned in school. B. expected of a nurse at that level. C. identified in the hospital's job description. D. requiring technical rather than professional skills. •Rationale: Student nurses should never perform a task that is not in the job description of the facility with which they work. You are about to administer an oral medication and you question the dosage. You should: A. administer the medication. B. notify the physician. C. withhold the medication. D. document that the dosage appears incorrect. •Rationale: If you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor. A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies A. Team nursing. B. Primary nursing. C. Functional nursing. D. Decentralized management. A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to A. Assign only bed-making and feeding skills. B. Assess the knowledge of the certified nursing assistant. C. Remind the staff member that she is working under the license of the RN. D. Allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform. What are the Five Rights of Delegation (select all that apply) A.Right Task B.Right Circumstance C.Right Person D.Right Place E.Right Direction F.Right Supervision G.Right Day A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: A. maturational. B. situational. C. sociocultural. D. posttraumatic. You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A. an increased appetite. B. an increased heart rate. C. a decrease in perspiration. D. a decrease in respiratory rate. IN CLASS: Light sleep and slowing brain and body processes are associated with which stage of NREM sleep? a. I b. II c. III d. IV These are characteristics of a person in Stage II of NREM sleep. --------------- Stages go by level of sleep you are I—lightest stage closest to consciousness IV—deep sleep The nurse is caring for a hospitalized patient who normally works the night shift at his job. The patient states, "I don't know what is wrong with me. I have been napping all day and can't seem to think clearly." The nurse's best response is a."You are sleep deprived, but that will resolve in a few days." b."You are experiencing hypersomnia, so it will be important for you to walk in the hall more often." c."There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" d."I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep." For which sleep disorder would the nurse most likely need to include safety measures in the patient's plan of care? a.snoring b.enuresis c.narcolepsy d.hypersomnia Narcolepsy can occur suddenly during the daytime hours when a person is involved in any type of activity. This could put the person at risk for harm depending on the activity in which he is engaged An example of a secondary health prevention activity would be a. Chemotherapy IV infusion b. Hepatitis B vaccine series c. Gallbladder surgery d. Flexible sigmoidoscopy at age 50 The American Cancer Society recommends that beginning at age 50, both men and women at average risk for developing colorectal cancer should use one of several screening exams. Health-screening activities are included in the definition of secondary health prevention. d. = a screening A=tertiary B=primary C= tertiary The patient newly diagnosed with Type II DM needs to make lifestyle changes. In relationship to the trans-theoretical model of change, which nursing action would best support the patient during the "contemplation" stage? a. Showing the patient how to use the finger-stick blood glucose monitor b. Providing information about various types of exercise to facilitate weight loss c. Teaching the patient about the purpose for having his HbA1C tested monthly d. Telling the patient that if he doesn't change his lifestyle, he will die Providing information about exercise would help the patient to decide what changes would best fit his personal goals. The contemplation stage involves the decision-making process. This person just go diagnosed They haven't started it a. Action C. Maintenance d. We wouldn't say that The client with multiple sclerosis can no longer walk or urinate on her own. She spends her day sewing quilts, reading, and communicating via e-mail with a support organization. This client is a. Healthy b. Ill c. In poor health d. Well The data suggests that despite physical incapacities, the client continues to live life as fully as possible. Not healthy b/c she has MS but not ill b/c she can do other things; not in poor health so must be well ------if that person is waiting for that day to come they would be in POOR HEALTH What is the goal of using a client history assessment tool to gather data about nutrition, exercise, leisure activities, spirituality, and home environment? a. To gather data required by insurers and regulatory agencies b. To assist the physician in developing a medical diagnosis c. To gather data about the causes of the client's illness d. To increase the client's awareness of lifestyle choices and his or her role in wellness The client has received a prescription for a metered-dose inhaler from the care provider. Before the client leaves the clinic, the nurse instructs the client on how to use the inhaler. The nurse is tending to the client's need in which stage of illness behavior? a. Dependence on others b. Sick role behavior