Homework Lance
1. A client thinks that she might be pregnant. Which first trimester physiological changes would most likely indicate this?
1.
Amenorrhea and nausea
2.
Braxton Hicks contractions
3.
Increased urinary frequency
4.
Edematous ankles and dyspnea
ANS: 1
Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first trimester. Braxton Hicks contractions are noted during the second trimester of pregnancy. Increased urinary frequency is commonly seen in the third trimester of pregnancy. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy.
DIF: A REF: 183 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/Specific Systems Assessment
2. 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:
1.
“Have you ever been married?”
2.
“Where do you currently work?”
3.
“Has anyone ever taught you about contraception?”
4.
“Who do you have for support during this pregnancy?”
ANS: 4
This could be a situational crisis for a single-parent family. The nurse should assess environmental and familial factors, including support systems and coping mechanisms commonly used. Asking the client whether she has ever been married does not assess her ability to cope with the pregnancy. Asking the client where she works may help determine if there are any environmental factors that may place her pregnancy at risk, but it does not assess her ability to cope with the pregnancy. This would not be the most opportune time to discuss contraception with the client and may convey a message of disapproval. Nor does asking the client about contraception assess her ability to cope with the pregnancy.
DIF: B REF: 181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Stress Management
3. The nurse is performing a physical examination on a 40-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging?
1.
Decreased hearing acuity
2.
Decreased sense of smell
3.
Decreased strength of abdominal muscles
4.
Decreased function of the various cranial nerves
ANS: 3
A physiological change related to normal aging in the middle adult would be decreased strength of abdominal muscles. The middle adult should have normal auditory structures and acuity. The middle adult should have a normal sense of smell. The middle adult should have normal functioning of the cranial nerves.
DIF: A REF: 185 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Reduction of Risk Potential/Specific Systems Assessment
4. A 49-year-old client is experiencing problems with depression. She has come to the clinic showing signs of malnutrition and fatigue. Which of the following is the best initial statement for the nurse to make in the assessment phase?
1.
“How much weight have you lost over the past month?”
2.
“Have you recently been experiencing menopausal symptoms?”
3.
“Depression is something to expect at your age, and with assistance you will get better.”
4.
“Your depression is somewhat uncommon. Can you tell me what has happened recently to cause it?”
ANS: 2
Mood changes and depression are common phenomena during menopause, and this client is in the expected age range to be experiencing menopause. Asking the client about weight loss may be an indication to verify depression; however, it is not the best initial response. Depression is not something to expect, although it can occur. Depression is not uncommon during menopause.
DIF: C REF: 186 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Stress Management
5. The nurse, trying to promote positive health habits regarding stress management is aware of the external influences on young and middle adult clients. With this knowledge, the nurse recognizes that an effective strategy for this age-group is:
1.
Teaching clients to abstain from all alcohol consumption
2.
Demonstrating how to take an accurate blood pressure measurement
3.
Determining an effective daily exercise schedule for stress reduction
4.
Describing the types of medications commonly used for treating depression
ANS: 3
Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young and middle adults. Exercise is a positive health habit for this age-group. Clients do not have to abstain from all alcohol consumption. Teaching clients to abstain from excessive alcohol consumption is important, but it is not a proactive positive health habit to help reduce stress. Monitoring one’s blood pressure may be important, but it is not a proactive positive health habit to help reduce stress. Teaching clients about types of medication used for treating depression does not help the client develop positive health habits for reducing stress.
DIF: A REF: 182 OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Lifestyle Choices
6. Individuals at the young adult point in their life are generally expected to, according to developmental patterns:
1.
Continue physical growth
2.
Experience severe illnesses
3.
Ignore physical symptoms
4.
Seek frequent medical care
ANS: 3
Young adults generally are quite active, experience severe illnesses less commonly than older age-groups, tend to ignore physical symptoms, and often postpone seeking health care. Young adults generally do not continue their physical growth. Young adults experience severe illnesses less commonly than older age-groups. Young adults often postpone seeking health care.
DIF: A REF: 178 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development
7. A nurse is preparing an education program on safety for a young adult group. Based on the major cause of mortality and morbidity for this age-group, the nurse should focus on:
1.
Birth control
2.
Automobile safety
3.
Occupational hazards
4.
Prevention of heart disease
ANS: 2
Violence is the greatest cause of mortality and morbidity in the young adult population. Deaths and injury from motor vehicle accidents are significant among this age-group. Unplanned pregnancies may be a source of stress but is not the major cause of mortality and morbidity in the young adult population. Exposure to work-related hazards or agents may cause diseases and cancer, but it is not the major cause of mortality and morbidity in this age-group. Developing healthy habits to prevent heart disease later in life is important, but heart disease is not the leading cause of mortality and morbidity for the young adult.
DIF: A REF: 181 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development/Lifestyle Choices
8. A nurse is working in the health office at a local college where most of the students are young adults. Being aware of the major concerns for this age-group, the nurse includes assessment of these clients’:
1.
Current marital history status
2.
Lifestyle and leisure activities
3.
Experience with chronic disease
4.
History of childhood accidents
ANS: 2
The young adult client may benefit from a personal lifestyle assessment to help identify habits that increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases. Assessing a client’s marital status does not offer much information about the client’s health or risk for future illnesses. Assessing a client’s experience with chronic disease is less appropriate for this age-group. Assessing the client’s history of childhood accidents does not offer much information about the client’s current health or risk for future illnesses.
DIF: A REF: 179 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development/Lifestyle Choices
9. As an individual enters middle adulthood health problems generally become more prevalent. The middle adult may be influenced by chronic illness that results in:
1.
Decreased health care tasks
2.
Reinforcement of family roles
3.
Changed sexual behavior habits
4.
Improvement of family relationships
ANS: 3
A few examples of the problems experienced by clients who develop debilitating chronic illness during adulthood include role reversal, changes in sexual behavior, and alterations in self-image. Chronic illness would result in increased health care tasks. Family roles are often changed with chronic illness, not reinforced. Strained family relationships may result from chronic illness.
DIF: A REF: 186 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development
10. The nurse is performing a physical examination on a 58-year-old adult client. The nurse will most likely find that the client of this age is experiencing which one of the following physiological changes related to normal aging?
1.
Palpable thyroid lobes
2.
Decreased skin turgor
3.
Reduced pupillary reaction
4.
Increased range of joint motion
ANS: 2
There is a slow, progressive decrease in skin turgor in the middle adult. The thyroid lobes should not be palpable in the middle adult. Pupillary reaction to light and accommodation should not change in the middle adult. A normal change in the middle adult is a decreased range of joint motion.
DIF: A REF: 221 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development
11. The nurse is alert to stressors that may have an influence on the young adult client. One example of a common stressor for this age-group is:
1.
Occupational pursuits
2.
Health-related matters
3.
Coping with cognitive changes
4.
Caring for the older adult parent
ANS: 1
A common stressor for the young adult is job stress. Health-related matters are not common stressors for the young adult. Coping with cognitive changes is not a common stressor for the young adult. Caring for older adult parents is more often seen with the middle adult, not the young adult.
DIF: A REF: 182-183 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Psychosocial Integrity/Stress Management
12. A client who works in a dry cleaning establishment comes to the clinic for a regular check-up. Based on this information, the nurse assesses the client for:
1.
Asbestosis
2.
Dermatitis
3.
Tendonitis
4.
Raynaud’s phenomenon
ANS: 2
Persons who work in dry cleaning establishments are exposed to solvents that may cause dermatitis or liver disease. Asbestosis is more likely to be found as an occupational hazard for automobile workers and insulators. Tendonitis may result from repetitive wrist motion as seen in office computer workers. Raynaud’s phenomenon may result from vibration as seen with jackhammer operators.
DIF: C REF: 182 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Reduction of Risk Potential/Specific Systems Assessment
13. The nurse is completing a physical exam for a 45-year-old client who has come to the family practice office. In evaluating the observations made during the examination, the nurse recognizes that an expected finding for a client in this age-group is:
1.
Hepatomegaly
2.
Visual acuity below 20/50
3.
An oral temperature of 39° C
4.
Increased amount of skin turgor
ANS: 2
The visual acuity tested by the Snellen chart should be less than 20/50. Hepatomegaly is not an expected finding and would be considered abnormal. Oral temperature should be 36.1 to 37.6° C. The expected finding would be a slow, progressive decrease in skin turgor.
DIF: A REF: 221 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Reduction of Risk Potential/Specific Systems Assessment
14. When discussing the stressors felt by a single mother in her 30s, the nurse recognizes that the greatest financial impact on this family is caused by:
1.
The ever-rising cost of living in the United States
2.
The realization that a female earns 25% less than her male co-worker
3.
Court-ordered child support is often times inadequate.
4.
Daycare expenses are a strain on a single wage earner family
ANS: 2
According to the AFL-CIO (2004) workers’ union, women in the United States are paid 76 cents for every dollar men receive for comparable work. This fact has an all-encompassing effect on the single-parent household. The cost of living is rising; it is not unique to the single mother. While court-ordered support often is inadequate, it does not have the impact that earning power has on the family income. While daycare expenses can be a strain, does not have the impact that earning power has on the family income.
DIF: C REF: 178 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Family Dynamics
15. Because young adults are less likely to experience serious illness, which of the following nursing interventions is most effective in determining risk for illness in this age-group?
1.
Health screenings
2.
Personal lifestyle assessment
3.
Full body systems assessment
4.
Cardiopulmonary focal assessment
ANS: 2
A personal lifestyle assessment (see Chapter 6) helps nurses and clients identify habits that increase the risk for cardiac, malignant, pulmonary, renal, or other chronic diseases. Health screening helps detect the presence of disease processes. Full body systems assessment would determine deviation from normal but not necessarily identify risk for illness. Cardiopulmonary focal assessment would determine deviation from normal but not necessarily identify risk for illness.
DIF: B REF: 178 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk for Injury; Physiological Integrity/Specific System Assessment
16. Research has shown that certain postpartum factors negatively affect a woman’s general health status after pregnancy. Which of the following women has the greatest risk factor for poor postpartum health?
1.
A mother with complaints of fatigue, loss of appetite, and insomnia
2.
A practicing attorney who has reluctantly taken a 3-month maternity leave
3.
A stay-at-home mom who gave birth 2 months ago and whose husband recently lost his job
4.
A mother of a 3-week-old and a 2-year-old whose military husband is currently deployed overseas
ANS: 4
Postpartum stress and depression have significant effects on postpartum women’s health. In addition, a lack of social support can affect women’s health adversely. This woman is the most likely mother to be experiencing depression and economic stressors as well as a lack of support. While fatigue, loss of appetite, and insomnia may be reflective of depression, there are no indications of the other high-risk factors. While this woman may be experiencing anxiety over being away from her career for 3 months, there is no indication of the other risk factors. While this mother may well be at risk for depression and possible financial stressors, there is no indication of a lack of support.
DIF: C REF: 180 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Family Systems
17. The nurse is preparing to discuss postpartum depression as a part of discharge teaching with the parents of a newborn. Which of the following nursing actions would be most therapeutic regarding early detection of this postpartum condition?
1.
Helping the couple understand the importance of social interaction with other adults
2.
Providing the couple with a video that tells the story of a new mother’s experience with depression
3.
Encouraging the couple to attend parenting classes designed to minimize the stressors of parenting an infant
4.
Having a discussion with the father in which he identifies the signs and symptoms of postpartum depression
ANS: 4
Educating both new mothers and their families regarding the signs and symptoms of postpartum stress and depression will facilitate early detection and treatment of the condition. While preventing social isolation is important to the prevention of generalized depression, it has little impact on detecting the signs and symptoms of the condition. While the video may be informative it is not the most therapeutic option because it lacks interaction between the nurse and the clients. While Option 3 is appropriate in regard to minimizing the risk of developing depression stemming from postpartum stressors, it does not directly impact the identification of the signs and symptoms of the condition.
DIF: C REF: 180 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Family Systems; Psychosocial Integrity/Stress Management/Crisis Intervention
18. Which of the following young adults is at greatest risk for experiencing death or injury?
1.
An 18-year-old with a father who is an alcoholic
2.
A 30-year-old who is a professional rodeo rider
3.
A 20-year-old living in an urban housing project
4.
A 26-year-old riding a motorcycle across the country
ANS: 3
Violence is the greatest cause of mortality and morbidity in the young adult population. Factors that predispose individuals to violence, injury, or death include poverty, family breakdown, child abuse and neglect, repeated exposure to violence, and ready access to guns. This option represents an individual who most likely is both poor and exposed to an environment of repeated violent acts. While Option 1 represents a potential for physical and mental abuse, it does not present the level of potential violence existing in Option 3. While Option 2 represents a potential for physical injury and possible death, it does not present the level of potential violence existing in Option 3. While Option 4 represents a potential for physical injury and possible death, it does not present the level of potential violence existing in Option 3.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk for Injury
19. The most serious risk for death for a young adult living in rural poverty is:
1.
Suicide
2.
Homicide
3.
Poor health maintenance practices
4.
Family history of chronic illnesses
ANS: 1
A young adult is more likely to die of self-inflicted injury when living at or below the poverty level when no other risk factors (i.e., a violent environment, drug abuse, etc.) are present. In 2002 the death rate (per 100,000 population) for 25- to 34-year-olds in the United States caused by homicide was 11.2; the death rate caused by accidents was 31.5; and the death rate caused by suicide was 12.6 (U.S. Department of Health and Human Services [USDHHS]).
DIF: C REF: 13 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Stress Management/Crisis Intervention
20. During a routine physical assessment a 27-year-old client acknowledges the suspension of his driver’s license because of an arrest for driving under the influence of alcohol. This admission should prompt the nurse to discuss which of the following in detail with the client?
1.
Use of illegal drugs
2.
History of depression
3.
Unprotected sexual experiences
4.
Tendency toward violent behavior
ANS: 1
Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for you to investigate the possibility of drug abuse more carefully. A history of depression is not necessarily a risk factor for illegal drug abuse. Unprotected sex is not necessarily a risk factor for illegal drug abuse. A tendency toward violent behavior is not necessarily a risk factor for illegal abuse.
DIF: C REF: 181 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk Behaviors; Psychosocial Integrity/Chemical Dependency
21. In preparing to discuss safe sex practices with a 20-year-old, it is most important that the nurse shares with the client that in addition to physical symptoms of genital pain and discharge, sexually transmitted diseases:
1.
Can lead to chronic illness and infertility
2.
Are particularly common in young adults
3.
Respond well to treatment when detected early
4.
May be effectively controlled through the use of condoms
ANS: 2
Sexually transmitted diseases (STDs) remain a major public health problem for sexually active persons, with almost half of all new infections occurring in men and women younger than 24 years of age (USDHHS, CDC, 2004). While Option 1 is true, it is vitally important that the nurse first share the high probability of contracting a STD to a sexually active young adult who practices unprotected sex. While some STDs respond well to early treatment, some, such as genital herpes and human immunodeficiency virus (HIV), can only be managed because no cure is currently available. While Option 4 may be true, it is vitally important that the nurse first share the high probability of contracting a STD in a sexually active young adult who practices unprotected sex.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk Behaviors
22. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult?
1.
Alcohol and tobacco use
2.
Ignoring seat belt and helmet laws
3.
Unprotected sex with multiple partners
4.
Poor nutrition and a lack of structured exercise
ANS: 1
Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic illnesses or disabilities during their middle or older adult years. While ignoring seat belt and helmet laws represents a risk factor for injury or death it is not directly related to chronic illness. While unprotected or multiple-partner sex option does represent a risk factor for chronic disease in the form of STDs, the greater risk comes from alcohol and tobacco use. While poor nutrition and lack of exercise do represent risk factors for chronic disease such as heart disease and obesity, the greater risk comes from alcohol and tobacco use.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk Behaviors
23. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults?
1.
“Unprotected sex is just plain dangerous.”
2.
“Everyone riding in my car wears a seatbelt.”
3.
“I’m a vegetarian, but I eat nonanimal protein.”
4.
“I’ve never smoked and I drink only occasionally.”
ANS: 4
Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in middle and older adult years. While Option 1 shows an understanding of the risk factor for chronic disease in the form of STDs, the greater risk comes from alcohol and tobacco use. While Option 2 shows an understanding of the risk factor for injury and death caused by vehicular accidents, it is not directly related to chronic illness.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk Behaviors
24. Which of the following lifestyle choices poses the greatest risk for chronic illness to the young adult?
1.
Alcohol and tobacco use
2.
Ignoring seat belt and helmet laws
3.
Unprotected sex with multiple partners
4.
Poor nutrition and a lack of structured exercise
ANS: 1
Lifestyle choices of young adults (e.g., use of tobacco or alcohol) put them at risk for chronic illnesses or disabilities during their middle or older adult years.
DIF: C REF: 180-181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk Behaviors
25. Which of the following client responses shows the best understanding regarding the management of risk factors for chronic illness among young adults?
1.
“Unprotected sex is just plain dangerous.”
2.
“Everyone riding in my car wears a seat belt.”
3.
“I’m a vegetarian, but I eat non-animal protein.”
4.
“I’ve never smoked, and I drink only occasionally.”
ANS: 4
Tobacco use and the abuse of alcohol put young adults at high risk for chronic illnesses in their middle and older adult years.
DIF: C REF: 180-181 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk Behaviors
26. Which of the following client responses shows the best understanding regarding the management of risk factors for acquiring a sexually transmitted disease (STD) among young adults?
1.
“I may want to have children someday, so I need to be careful.”
2.
“Even though there are treatments for STDs, I don’t take chances.”
3.
“There is certainly enough literature out there on the use of condoms.”
4.
“Having unprotected sex with someone my age is very risky business.”
ANS: 4
Sexually transmitted diseases (STDs) remain a major public health problem for sexually active persons, with almost half of all new infections occurring in men and women younger than 24 years of age (USDHHS, CDC, 2004).
While it is true that some STDs can result in infertility, this option doesn’t show the greatest understanding since it focuses on only one outcome.
While some STDs respond well to early treatment, some STDs, such as genital herpes and human immunodeficiency virus (HIV), can only be managed since a cure is not currently available.
DIF: C REF: 181 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: : Health Promotion and Maintenance/High Risk Behaviors
27. Which of the following statements made by a 27-year-old client shows the greatest need for further nursing assessment regarding the potential use of illegal drugs?
1.
“Whether you wear a helmet or not should be the choice of the motorcyclist.”
2.
“I fractured my hand 3 years ago when I got so mad I hit a wall in my dorm room.”
3.
“I like to drink a bit too much, and I lost my license once for drinking and driving.”
4.
“My father suffered from depression when he lost his job, and he still takes medication for it.”
ANS: 3
Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for you to investigate the possibility of drug abuse more carefully.
A tendency toward high-risk behavior such as extreme sports or not using safety equipment is not necessarily a risk factor for illegal drug use.
A tendency toward violent behavior is not necessarily a risk factor for illegal drug abuse.
A family history of depression is not necessarily a risk factor for illegal drug abuse.
DIF: C REF: 181 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/High Risk Behaviors
28. Which of the following statements made by the parents of a newborn best reflects an understanding regarding the diagnosis of postpartum depression?
1.
“I helped my sister when she was depressed after the birth of her second child.”
2.
“I have a wonderfully supportive family who will be there if I start feeling depressed.”
3.
“We’ve read over the literature, and I’ll be able to recognize any signs of depression in my wife.”
4.
“Most new moms get a little depressed, but we will be sure to pay attention to any real indications of a problem.”
ANS: 3
Having someone in close contact with the new mom available to assess her for possible signs of postpartum depression shows both an understanding of the condition as well as a desire to manage it if it occurs.
DIF: C REF: 180 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/ Family Systems; Psychosocial Integrity/Stress Management/Crisis Intervention
29. Which of the following questions asked by the nurse best assesses for the signs of pregnancy most likely observed in the second trimester?
1.
“Have you had any problems climbing steps?”
2.
“Have you noticed any cramping in your abdomen?”
3.
“Have you experienced any nausea in the morning?”
4.
“Have you had any problems with shoes that don’t seem to fit?”
ANS: 2
Braxton-Hicks contractions are noted during the second trimester of pregnancy.
Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy.
Amenorrhea and nausea are physiological changes that may indicate pregnancy in the first trimester. Edematous ankles and dyspnea may be experienced during the third trimester of pregnancy.
DIF: C REF: 183 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/ Reduction of Risk Potential/Specific Systems Assessment
30. Which of the following client statements would be the best evidence that this young adult has adopted a positive strategy to promote his own personal emotional health?
1.
“I drink alcohol only on special occasions and then moderately.”
2.
“I run at least three times a week; it seems to help me stay relaxed.”
3.
“I watch for the signs of depression since my mother experienced it.”
4.
“I know stress can affect my blood pressure, so I have it taken regularly.”
ANS: 2
Exercise on a routine basis can be an effective strategy to reduce the stress experienced by young and middle adults. Exercise is a positive emotional health habit for this age group.
Drinking alcohol in moderation is certainly a positive health habit, but it does not have the strongest impact on emotional health of the available options.
DIF: C REF: 181 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Lifestyle Choices; Psychosocial Integrity/Coping Mechanisms
31. Which of the following client statements, made by a young adult regarding health promotion habits, reflects a need for further client education by the nurse?
1.
“I go to the gym and work out 3 times a week with friends.”
2.
“My dad has high cholesterol, so I have mine checked yearly.”
3.
“Diabetes runs in my family, so I watch my carbohydrate intake.”
4.
“I drink alcohol only on weekends, when it doesn’t interfere with work.”
ANS: 4
The correct answer reflects a poor understanding of alcohol abuse. The primary criterion for healthy alcohol consumption is not drinking only when it will not affect work. Further education regarding responsible alcohol consumption and alcoholism is appropriate. The other options reflect a good understanding of health promotion habits.
DIF: C REF: 181 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Lifestyle Choices; Psychosocial Integrity/Coping Mechanisms
32. Which of the following nursing assessment questions is best directed toward determining the presence of a normal physiological change experienced by a middle-aged client?
1.
“Any problems with your teeth or gums?”
2.
“Any family history of thyroid problems?”
3.
“Do you have a skin-moisturizing routine?”
4.
“Are you having a problem with driving at night?”
ANS: 3
There is a slow, progressive decrease in skin turgor in the middle-aged adult.
Dental problems are not a normal physiological change seen in the middle-aged adult.
Thyroid problems are not a normal physiological change seen in the middle-aged adult.
Night blindness is not a normal physiological change seen in the middle-aged adult.
DIF: C REF: 185 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development
33. Which of the following nursing assessment questions is best directed toward determining the presence of an occupational hazard-related condition specific for a client working in a dry cleaning establishment?
1.
“Do you have any problems with rashes or itching?”
2.
“How long have you worked in the dry cleaning business?”
3.
“Do you treat the minor burns you experience?”
4.
“Do you drive the company van to make deliveries?”
ANS: 1
Persons who work in dry cleaning establishments are exposed to solvents that may cause dermatitis or liver disease. While asking about the length of time employed is an appropriate assessment question, it is not directed toward identifying a response to any specific risk factor. While burns may be a risk factor for those working in the dry cleaning industry, the risk is not as specific as assessing for contact dermatitis.
While automobile accident-related injuries may be a risk factor in this case, the risk is not as specific as assessing for contact dermatitis.
DIF: C REF: 182 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/ Reduction of Risk Potential/Specific Systems Assessment
34. Which of the following nursing assessment questions is best directed toward determining the presence of career stressors in a young adult?
1.
“What do you do to relieve stress for yourself?”
2.
“What is the most stressful part of your daily job?”
3.
“Career-wise, where would you like to be in 2 years?”
4.
“Do you miss much work as a result of injuries or illness?”
ANS: 2
The correct option is an open-ended question that encourages the client to identify and discuss work-related stressors, which are a major source of stress for this age group.
DIF: C REF: 182-183 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Psychosocial Integrity/Stress Management
35. Which of the following statements concerning health promotion habits made by a young adult best reflects an understanding regarding the primary cause of death and injury among that age group?
1.
“Eating a healthy, low-fat diet is very important to me.”
2.
“AIDS is nothing to mess with, so I always practice safe sex.”
3.
“Regardless of what my friends say, I always wear a seat belt.”
4.
“I enjoy mountain biking, but I always wear the right protection gear.”
ANS: 3
Deaths and injury from motor vehicle accidents are significant among this age group.
Developing healthy habits to prevent heart disease later in life is important, but heart disease is not the leading cause of mortality and morbidity for the young adult.
Sexually transmitted diseases are a risk factor for this age group, but they do not represent the greatest risk for death and injury.
An injury related to occupation and recreation is a risk factor, but it is not the major cause of mortality and morbidity in this age group.
DIF: C REF: 181 OBJ: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development/Lifestyle Choices
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