Answers and Explanations

Chapter Quiz

The Answer is 3
A 20-year-old client has just given birth. The baby looks healthy, with the exception of giving a grimace instead of a cry. Which of the following would the nurse expect the obstetrician to say?

Category: Ante/intra/postpartum and newborn care
1. An APGAR score of 3 indicates a baby in poor health.
2. An APGAR score of 6 indicates a less healthy baby.
3. CORRECT: In 4 of the 5 categories of rating, the baby scored a 2. In the category of reflex irritability, the baby scored a 1, for a total APGAR score of 9.
4. An APGAR score of 12 does not exist; the highest score is 10.
The Answer is 4
The outpatient client is postmenopausal. In discussing breast self-examination, which of the following should the nurse let the client know that she can do?

Category: Aging process
1. Although menopause itself is not associated with increased risk of breast cancer, the rate does increase with age. The client should continue with breast self-examination.
2. Although menopause itself is not associated with increased risk of breast cancer, the rate does increase with age. The client should continue with breast self-examination.
3. Although menopause itself is not associated with increased risk of breast cancer, the rate does increase with age. The client should continue with breast self-examination.
4. CORRECT: Breast self-examination is extremely important for a client in this soon-to-be high risk group. About 70 percent of new diagnoses come after age 50.
The Answer is 1
A client with acne has been using isotretinoin. She tells the nurse that she recently learned she is pregnant. She asks “Will my pregnancy interfere with the medication’s effectiveness?” Which of the following is the appropriate response by the nurse?

Category: Ante/intra/postpartum and newborn care
1. CORRECT: Severe fetal abnormalities may occur if isotretinoin is used during pregnancy. The nurse should stress that the priority is the high risk of fetal abnormalities that the medication can cause rather than the effectiveness of the medication.
2. The nurse would not tell the client to continue taking this drug.
3. The nurse would not tell the client to continue taking this drug.
4. The nurse would not tell the client to continue taking this drug.
The Answer is 2
The nurse is preparing for a women’s health fair. The nurse knows that which of the following is correct when teaching about the risks and benefits of hormone replacement therapy (HRT)?

Category: Health promotion/disease prevention
1. HRT causes an increased risk of DVT.
2. CORRECT: Current research counteracts earlier theories of a decreased risk of CAD.
3. HRT causes a decreased risk of osteoporosis-related bone fractures.
4. HRT causes an increased risk of breast cancer.
The Answer is 2
The nurse has been working with a 45-year-old African American who bicycles to work. Lab tests show low serum lipids. The nurse knows that the client’s risk factors for primary (essential) hypertension include which of the following?

Category: Health promotion/disease prevention; Health screening
1. Being under the age of 65 is associated with lower risk.
2. CORRECT: African Americans have an increased risk for hypertension.
3. Low serum lipids are associated with lower risk.
4. An active lifestyle is associated with lower risk.
The Answer is 3
The nurse is designing a diet plan for a 70-year-old with poorly fitting dentures who has been recently diagnosed with type 2 diabetes. The nurse knows that which of the following is the LEAST likely risk to the client?

Category: Health promotion/disease prevention
1. Malnutrition is a possibility due to difficulty in eating.
2. Dehydration is a possibility.
3. CORRECT: Hypoglycemia is more likely than hyperglycemia. Often a client with denture problems will only be able to tolerate liquid or pureed foods eaten slowly. This decreases the chances of adequate nutrition.
4. Low blood sugar is a possibility.
The Answer is 3
The nurse is providing education at a senior center. Which of the following measures will the nurse say is MOST effective in attaining normal blood sugar levels in a client with type 2 diabetes?

Category: Health and wellness
1. Decreasing sodium intake is not an effective way to attaining normal blood sugar levels in a client with type 2 diabetes.
2. More potassium and calcium will not affect blood glucose.
3. CORRECT: Losing only as much as 10–20 pounds improves blood glucose control.
4. The client needs to increase, not decrease, daily exercise.
The Answer is 3
A local high school is having a health fair. Which of the following main courses should the nurse recommend as most healthful for a teenager whose cholesterol level is 300 mg/dL?

Category: Health and wellness; Health promotion/disease prevention
1. The fat content of the main course (hamburger) needs to be lower due to the teenager’s known elevated cholesterol level.
2. The fat content of the main course (pizza) needs to be lower due to the teenager’s known elevated cholesterol level.
3. CORRECT: The fat content of a grilled chicken breast is the lowest of the choices.
4. The fat content of the main course (salad with extra dressing) needs to be lower due to the teenager’s known elevated cholesterol level.
The Answer is 4
The nurse is talking to a client who is still grieving the loss of a parent to stomach cancer. The nurse knows that which of the following would increase the client’s risk of cancer?

Category: Health promotion/disease prevention
1. High-protein diets have not been shown to be a risk for cancer.
2. Low-fat, low-carbohydrate diets have not been shown to be a risk for cancer.
3. Spicy food has not been shown to be a risk for cancer.
4. CORRECT: Tobacco use has been shown to be a risk for cancer.
The Answer is 2
A 3-month-old child accompanies her parents to a seasonal flu clinic. Assuming that the child does not have a fever, can the nurse give the child a flu shot?

Category: Aging process
1. The minimum age to receive a flu shot is 6 months; therefore the nurse cannot give the child the shot.
2. CORRECT: The minimum age to receive a flu shot is 6 months.
3. The minimum age to receive a flu shot is 6 months; therefore the nurse cannot give the child the shot.
4. The minimum age to receive a flu shot is 6 months; therefore the nurse cannot give the child the shot.
The Answer is 4
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 28th week of pregnancy. Which of the following client situations requires the nurse to take this action?

Category: Ante/intra/postpartum and newborn care
1. An Rh-positive mother does not need to worry about the Rh factor of the father.
2. An Rh-positive mother does not need to worry about the Rh factor of the father.
3. An Rh-negative mother does not need to worry about the Rh factor of the father, if it is the same as her status.
4. CORRECT: An Rh-negative mother and Rh-positive father is the combined Rh status in which the mother could develop harmful antibodies.
The Answer is 4
The nurse is teaching a young male client to recognize the most common early sign of testicular cancer. The nurse emphasizes the fact that he should be aware of which of the following?

Category: Health promotion/disease prevention
1. Among other serious causes, lumbar pain could be a sign of metastasis.
2. Urinary frequency is not an early sign of testicular cancer.
3. Urinary urgency is not an early sign of testicular cancer.
4. CORRECT: Painless testicular enlargement is a common early sign of testicular cancer.
The Answer is 2
New parents are concerned about an unexpected characteristic of their newborn baby. Which of the following would cause the nurse to initiate contact with the physician?

Category: Ante/intra/postpartum and newborn care
1. Swollen genitals and breast are normal due to maternal hormones.
2. CORRECT: High-pitched crying is not normal and could be due to a neurological problem.
3. A misshapen head is normal due to descent through the birth canal.
4. Milia is normal due to blocked sebaceous glands.
The Answer is 4
A public health nurse visits a client at home three days after the client gave birth. In which of the following situations should the nurse instruct the client to report to a clinician?

Category: Ante/intra/postpartum and newborn care
1. Vaginal drainage with streaks of bright red blood is normal for the first 3–6 weeks.
2. The area will continue to heal and is not a cause for concern, unless the discomfort rises to the level of persistent or increasing pain.
3. Feelings of fatigue are normal after giving birth.
4. CORRECT: A fever above 100.4° F (38° C) is reason to call the physician.
The Answer is 1, 2, 4, 5
The pediatric nurse is providing discharge instructions to the parents of a newborn. In which of the following situations would the nurse advise the parents to call a physician? Select all that apply.

Category: Ante/intra/postpartum and newborn care
1. CORRECT: If an infant has a fever higher than 100.4° F (38° C), the parents should call the physician.
2. CORRECT: If an infant vomits more than once in 24 hours, the parents should call the physician.
3. There would be no need to call the physician in this instance.
4. CORRECT: If an infant is unable to keep down food or water, the parents should call the physician.
5. CORRECT: A physician should evaluate the infant immediately if the infant has sunken or swollen soft spots on the head.
The Answer is 1
The client’s first day of her last period was February 1. Which of the following should the nurse tell the client is her expected date of delivery?

Category: Ante/intra/postpartum and newborn care
1. CORRECT: November 8 is 9 months and 7 days later.
2. October 8 is one month too early.
3. By December 1, the baby would be overdue.
4. By November 20, the baby would be overdue.
The Answer is 2
The client is 7 months pregnant with her first child. She is anxious because she feels some mild contractions at times. The nurse tells her which of the following?

Category: Ante/intra/postpartum and newborn care
1. Increasing bed rest is not necessary; Braxton Hicks contractions are normal at this stage in the pregnancy.
2. CORRECT: Braxton Hicks contractions are normal at this stage in the pregnancy.
3. More exercise is not necessary: Braxton Hicks contractions are normal at this stage in the pregnancy.
4. Gas is not likely to be the cause of the contractions; Braxton Hicks contractions are normal at this stage in the pregnancy.
The Answer is 3
The client is 40 years old and pregnant with her first child. Her obstetrician has asked the nurse to schedule her for an amniocentesis. The client inquires why she needs that test. The nurse says which of the following as an explanation?

Category: Ante/intra/postpartum and newborn care
1. The most common reason for an amniocentesis is to check chromosomal abnormalities, not to check the child’s gender.
2. The ultrasound is not invasive; the amniocentesis is invasive.
3. CORRECT: After age 35, the risk of infant chromosomal abnormality is greater than the risk associated with the procedure.
4. The most common reason for an amniocentesis is to check chromosomal abnormalities, not to check the baby’s size.
The Answer is 1
The nurse is educating a mother-to-be about possible danger signs during the last three months of pregnancy. Which of the following would NOT cause the nurse concern about danger signs?

Category: Ante/intra/postpartum and newborn care
1. CORRECT: Although hemorrhoids could cause rectal bleeding, it is vaginal bleeding that would concern the nurse.
2. Continuous headaches is a symptom that would concern the nurse.
3. Marked swelling of hands would concern the nurse.
4. Blurred vision would concern the nurse.
The Answer is 2, 3, 4, 5
A first-time parent is discussing developmental milestones with the nurse. The nurse tells the client that she can reasonably expect her child to achieve which of the following by the time the child is 1 year old? Select all that apply.

Category: Developmental stages and transitions
1. The parent should not become concerned unless the child cannot walk at 18 months.
2. CORRECT: Rolling from tummy to side is a developmental milestone that the client can expect the child to reach by age 1.
3. CORRECT: Transferring toys from hand to hand is a developmental milestone that the client can expect the child to reach by age 1.
4. CORRECT: Beginning to respond selectively to words is a developmental milestone that the client can expect the child to reach by age 1.
5. CORRECT: Vocalizing sounds (coos) is a developmental milestone that the client can expect the child to reach by age 1.
The Answer is 3
A parent is discussing the behavior of her 3-year-old child with the nurse. At 3 years, the nurse would expect the client’s child to be doing all of the following EXCEPT which activity?

Category: Developmental stages and transitions
1. Saying “no” often is an appropriate behavior at this age.
2. Using a limited vocabulary of 500–3,000 words is an appropriate behavior at this age.
3. CORRECT: Only three- or four-word sentences can be expected at this age.
4. Believing adults know everything is an appropriate behavior for this age.
The Answer is 1
The nurse is teaching a group of mothers of toddlers how to prevent accidental poisoning from medications. The nurse teaches the mothers to store medications in which of the following locations?

Category: Aging process; Developmental stages and transitions
1. CORRECT: A secure, locked place is the only safe place.
2. Children have been known to pull childproof caps off, especially if the cap is not fully engaged.
3. Children have been known to climb up on counters and other surfaces, so placing medications on a high shelf is not necessarily safe.
4. The problem is the toddler’s natural curiosity, not whether the toddler recognizes the item as a medication vial. If containers are disguised, this might also cause a medication error.
The Answer is 2
The nurse is assessing an elderly couple, both 80 years old, to determine if they can safely continue to live independently. They insist they are getting along fine but need help with grocery shopping and housekeeping. The nurse determines that they have difficulty in doing which of the following?

Category: Aging process; Self-care
1. ADLs are basic functions of self-care, such as feeding, dressing, and bathing.
2. CORRECT: Grocery shopping and housekeeping are two important IADL functions.
3. Grocery shopping and housekeeping are not milestones.
4. Grocery shopping and housekeeping are not prevention activities.
The Answer is 1
The nurse is giving a lecture at the senior center about preventative health activities for people over age 60. The nurse tells the clients that the Centers for Disease Control and Prevention (CDC) now recommends which of the following vaccines for this age group?

Category: Health promotion/disease prevention
1. CORRECT: The shingles vaccine reduces the risk of shingles by about half and the risk of postherpetic neuralgia by two-thirds.
2. The diphtheria vaccine is given much earlier in life.
3. The pertussis (whooping cough) vaccine is given much earlier in life.
4. The CDC recommends that college freshmen living in dormitories get the meningitis vaccine, but this is unlikely to apply to those over age 60.
The Answer is 1, 2, 4, 5
The nurse is teaching about the challenges of smoking cessation. Which of the following factors will the nurse identify as known challenges that clients face when attempting to quit smoking? Select all that apply.

Category: Health promotion/disease prevention; High risk behaviors
1. CORRECT: Stress and depression are known challenges to smoking cessation.
2. CORRECT: Continued smoking is more prevalent among those with a low level of income.
3. A low, not high, level of education has been found to be associated with continued smoking.
4. CORRECT: Continued smoking is more prevalent among those with psychosocial problems.
5. CORRECT: Continued exposure to smoking-associated stimuli is a known challenge to smoking cessation.
The Answer is 2, 3, 4
Stress reduction techniques include biofeedback and meditation. The nurse conducting classes on these methods knows that studies have shown a cause-and-effect relationship between stress and which of the following? Select all that apply.

Category: Health promotion/disease prevention
1. No association between stress and adverse medication effects is known at present.
2. CORRECT: Research shows a relationship between stress and infectious diseases.
3. CORRECT: Research shows a relationship between stress and traumatic injuries, such as motor vehicle accidents.
4. CORRECT: Research shows a relationship between stress and some chronic illnesses.
The Answer is 2
The nurse is performing the initial assessment of an adult from a culture the nurse is not familiar with, and asks about the client’s use of alternative therapies. The client says, irritably, “Do you have to ask all these questions?” Which of the following is the BEST explanation for what the nurse should do in response?

Category: Health screening
1. The client is the focus, not the nurse’s education.
2. CORRECT: The need to discuss the use of these adjunct therapies with clients in all settings is imperative. This is important because it could affect or interfere with other treatment modalities.
3. The client might become impatient, but that does not mean that the nurse shortens her clinical review.
4. The nurse needs to ask critical questions to get the complete clinical picture.
The Answer is 3
The nurse is preparing a community educational presentation. The topic is the leading cause of death for people from ages 1–44. The nurse knows that which of the following is the leading cause?

Category: Health promotion/disease prevention
1. Cancer is not the leading cause of death for people from ages 1–44, according to the CDC.
2. Heart disease is not the leading cause of death for people from ages 1–44, according to the CDC.
3. CORRECT: Unintentional injuries are the leading cause of death for people ages 1–44, according to the CDC.
4. Diabetes is not the leading cause of death for people from ages 1–44, according to the CDC.
The Answer is 1 (E), 2 (A), 3 (B), 4 (C), 5 (D)
The nurse is reviewing the client’s lipid profile to determine if education is needed to reduce the risk of heart disease. The nurse knows how to match healthy target values with lab descriptions. Match the appropriate part of the profile below on the left to the values on the right. All options must be used.

Category: Health promotion/disease prevention
1. (E): Total cholesterol should be less than 200 mg/dL.
2. (A): HDL cholesterol for men should be more than 40 mg/dL.
3. (B): HDL cholesterol for women should be more than 50 mg/dL.
4. (C): LDL cholesterol should be less than 100 mg/dL.
5. (D): Triglycerides should be less than 150 mg/dL.
The Answer is 1 (B), 2 (C), 3 (A)
The nurse is assessing the best approach to prepare three clients for surgery. Each has a different learning preference. Match the learning preference to the appropriate approach. All options must be used.

Category: Principles of teaching/learning
1. (B): Brochures about preparation activities are visual: the client needs to see words and pictures.
2. (C): Models of the relevant anatomy are tactile: the client needs to touch the model.
3. (A): Discussions about the surgery are auditory: the client needs to hear the words.