A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past
six months. The nurse should assess the woman for other symptoms of:
C
Explanation:
Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian
function
diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric
is a term
applied to the period of life in which physiologic changes occur and result in cessation of a woman’s
reproductive
ability and lessened sexual activity in males. The term applies to both genders. Climacteric and
menopause are
interchangeable terms when used for females. Menopause is the period when permanent cessation
of menses has
occurred. Postmenopause refers to the period after the changes accompanying menopause are
complete.Health
Promotion and Maintenance
When obtaining a health history on a menopausal woman, which information should a nurse
recognize as a contraindication for hormone replacement therapy?
D
Explanation:
Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history
of
stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history
of stroke or
other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or
night sweats
can be relieved by hormone replacement therapy.Health Promotion and Maintenance
Which of the following statements, if made by the parents of a newborn, does not indicate a need
for further teaching about cord care?
D
Explanation:
Parents should be taught to wash their hands before and after providing cord care. This prevents
transferring
pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows
for drying.
It also prevents wet or soiled diapers from coming into contact with the cord. Current
recommendations include
cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting
alcohol or other
antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and
Maintenance
The nurse is teaching parents of a newborn about feeding their infant. Which of the following
instructions should the nurse include?
A
Explanation:
Parents must be careful when warming bottles in a microwave oven because the milk can become
superheated.
When a microwave oven is used, the defrost setting should be chosen, and the temperature of the
formula should
be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after
4 hours
because the baby might have introduced some pathogens into the formula. Returning the bottle to
the refrigerator
does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one
part concentrate
and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles
should not have
fresh formula added to them. Pathogens can grow in partially used bottles of formula and be
transferred to the new
formula.Health Promotion and Maintenance
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse
expect to examine?
C
Explanation:
In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick
guide to
the number of teeth a child should have is as follows: Subtract the number 6 from the number of
months in the
age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-
month-old child
should have approximately 12 teeth.Health Promotion and Maintenance
Which of the following physical findings indicates that an 11–12-month-old child is at risk for
developmental dysplasia of the hip?
B
Explanation:
The nurse might be concerned about developmental dysplasia of the hip if an 11–12-month-old child
doesn’t
pull to a standing position. An infant who does not walk by 15 months of age should be evaluated.
Children
should start walking between 11–15 months of age. Trendelenberg sign is related to weakness of the
gluteus
medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or
dislocation of the
hip in infants.Health Promotion and Maintenance
When administering intravenous electrolyte solution, the nurse should take which of the following
precautions?
C
Explanation:
Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because
hypertonic
solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is
incorrect because
potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60
mEq/L.
Physiological Adaptation
Teaching about the need to avoid foods high in potassium is most important for which client?
D
Explanation:
Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in
potassium.
Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic
alkalosis
are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological
Adaptation
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24
mEq/L?
B
Explanation:
These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values
indicate none of these acid-base disturbances.Physiological Adaptation
The major electrolytes in the extracellular fluid are:
C
Explanation:
Sodium and chloride are the major electrolytes in the extracellular fluid.Physiological Adaptation
A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a
strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes.
Which of the following nursing measures is most appropriate to meet the expected outcome of
positive body image?
C
Explanation:
Teaching the client and family about progression of the disease includes explaining when symptoms
can
be expected to improve and resolve. Knowledge of the course of the disease can help them
understand that no
permanent disruption in physical appearance will occur that could negatively affect body image.
Clients with
Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary
artery lesions
and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to
body image.
The nurse assesses symptoms to assist in evaluation of treatment and progression of the
disease.Health
Promotion and Maintenance
Which of the following is most likely to impact the body image of an infant newly diagnosed with
Hemophilia?
D
Explanation:
Altered Family Processes is a potential nursing diagnosis for the family and client with a new
diagnosis of
Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an
immediate
impact on the infant’s development of trust and how others relate to them because of their
diagnosis. The longterm
effects of hemophilia can include problems related to immobility. Altered growth and development
could not
have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is
characteristic
of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed
hemophiliac.Health
Promotion and Maintenance
While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a
medicine woman be present in the examination room. Which of the following is an appropriate
response by the nurse?
A
Explanation:
This statement reflects cultural awareness and acceptance that receiving support from a medicine
woman is
important to the client. The other statements are culturally insensitive and unprofessional.Reduction
of Risk
Potential
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
C
Explanation:
Decreasing maternal fluids is the only intervention that shouldnotbe performed when fetal distress is
indicated.Reduction of Risk Potential
Which fetal heart monitor pattern can indicate cord compression?
A
Explanation:
Variable decelerations can be related to cord compression. The other patterns are not.Reduction of
Risk
Potential