Exam 3: NUR230 / NUR 230 (Latest 2026/2027 Update) Concepts of Nursing: The Childbearing/Child Caring Family | Questions & Answers | 100% Correct | Galen

Exam 3: NUR230 / NUR 230 (Latest 2026/2027 Update) Concepts of Nursing: The Childbearing/Child Caring Family | Questions & Answers | 100% Correct | Galen Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the perineal pad to be completely saturated with bright red blood over the last 15 minutes. The priority in this scenario is: A. Start a second intravenous line of Normal Saline B. Notify the primary health care provider C. Massage the fundus D. Assess vital signs C. Massage the fundus The nurse recognizes the following postpartum changes are normal EXCEPT: A. Low-grade fever (100.2) in the first 24 hours B. Profuse night-time sweating in the first few days postpartum C. WBCs of 40,000/mm3 D. Intense shivering in the first hour postpartum without feeling cold C. WBCs of 40,000/mm3 Related to uterine involution, the nurse recognizes all of the following statements are true EXCEPT: A. The fundus descends at a rate of about 1-2 cm every 24 hours. B. The uterus should not be palpable abdominally after 2 days. C. Oxytocin causes the uterus to contract, causing the hemostasis of blood vessels in the uterine myometrium. D. The most common causes of subinvolution are retained placental fragments and infection. B. The uterus should not be palpable abdominally after 2 days. If a postpartum client complains of extreme perineal pain, especially after having received pain medication, the FIRST action by the nurse should be: A. Notify the provider B. Apply an ice pack to the perineum C. Assess the perineum D. Check the client's vital signs and fundus C. Assess the perineum The nurse is performing a 1 minute APGAR assessment of a newborn infant. Appearance Body pink, hands blue pulse 118 bpmGrimace Minimal response activity Some flexion Respiration Slow and irregular What is the APGAR score? A. 8 B. 7 C. 6 D. 5 D. 5 The nurse checks a newborn's axillary temperature after giving a bath. What type of heat loss may occur as a result? A. Conduction B. Convection C. Radiation D. Evaporation D. Evaporation When newborn infants experience cold stress, they begin to metabolize brown fat stores. If the baby is not adequately warmed and the cold stress continues, which is NOT an anticipated outcome? A. Hypoglycemia B. Respiratory distress C. Hypertension D. Lethargy C. Hypertension Which of the following is NOT a risk factor associated with mastitis? A. Frequent feedings B. Cracked nipples C. Fatigue D. Inadequate emptying of the breast A. Frequent feedings You are caring for a couple who has a baby with a cleft lip and palate. Which statement, by the mother, displays that she understands priority interventions while feeding? A. We need to monitor for jaundice. B. We need to monitor for pain. C. We need to monitor for respiratory distress and aspiration. D. We need to monitor for hypoglycemia. C. We need to monitor for respiratory distress and aspiration. Which infants are at greatest risk of developing physiological jaundice? (Select all that apply) A. 3-hour-old infant born at term B. 2-day-old infant born at 35weeks C. An 18-hour-old SGA baby who is having difficulty breastfeeding D. A 2-day-old baby diagnosed with a cephalhematoma E. A 2-hour-old infant who is O-and the mother is B+ blood type B. 2-day-old infant born at 35weeks D. A 2-day-old baby diagnosed with a cephalhematoma An infant admitted to the NICU is exhibiting signs of neonatal abstinence syndrome. Which of the following behaviors would support this diagnosis? A. High-pitched shrill cry B. Hyper-dynamic precordium C. Depressed fontanels D. Excessive regurgitation A. High-pitched shrill cry Rubin describes one of the phases of maternal postpartum adjustment as "Mothers focus attention on themselves and their recovery needs. Mothers are dependent on others to make decisions and to care for their newborns." Which phase is she describing? A. Taking in B. Letting in C. Taking hold D. Letting go A. Taking in What is the purpose of giving newborns Vitamin K/Phytonadione? A. It helps newborns create intestinal bacteria B. Given to prevent hemorrhage due to lack of Vit K in the gut C. It aids in the digestion of baby's first feedings D. Given to enhance newborn immunity B. Given to prevent hemorrhage due to lack of Vit K in the gut Which of the following findings indicates respiratory distress in the newborn when all are present simultaneously? SATA A. Respiratory rate 70 B. Apnea for 10 seconds C. Intercostal retractions D. Acrocyanosis E. Grunting F. Nasal Flaring A. Respiratory rate 70 C. Intercostal retractions E. Grunting F. Nasal Flaring Erythromycin eye ointment is administered to newborns after delivery to help which of the following? SATA A. Treat discharge from leaking from the eyes B. Prevent conjunctivitis C. Prevent complications associated with gonorrhea D. Prevent Group B Strep infections vertically transmitted from the mother E. Prevent neonatal blindness B. Prevent conjunctivitis C. Prevent complications associated with gonorrhea E. Prevent neonatal blindness Which vaccine does the newbornreceive before discharge? A. Rubella B. Hepatitis B C. Hepatitis C D. Tdap B. Hepatitis B An infant born at 35 weeks gestation experiences grunting in the newborn nursery. What action is the priority? A. Place a pacifier in the baby's mouth B. Assess the respiratory rate C. Have the mother breastfeed the infant D. Assess the infant's pulse B. Assess the respiratory rate According to the National Council of State Boards of Nursing (NCSBN), which rights of delegation should the nurse follow? Standard Text: Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task 1. Supervision 2. Evaluation 5. Task An unlicensed assistive person (UAP) is working on a rehabilitation unit. Which task would be appropriate for this person to delegate? 1. Taking and recording vital signs 2. Assisting with bathing 3. Making a bed 4. An unlicensed assistive person may not delegate tasks. 4. An unlicensed assistive person may not delegate tasks. An RN delegates the task of taking a newly admitted clients vital signs to a nurses aide. The clients blood pressure was 182/98, but did not get reported to the physician for several hours. Who is responsible for the lapse in time between discovery and action? 1. Nurse manager 2. Aide 3. Client 4. RN 4. RN A nurse manager has the reputation of being an autocratic leader. Which of the following statements by this manager would support that reputation? 1. Id like to hear from you (addressing the staff) what your ideas are for promoting better morale in this unit. 2. Im putting a suggestion box in the break room if anyone has ideas that would be helpful to the unit. 3. The new work schedule is posted for the next 6 weeks. 4. I put the new procedure manual out. Please add your comments to the blank sheet of paper attached to the front. 3. The new work schedule is posted for the next 6 weeks. During a particularly heated staff meeting regarding staff assignments, the nurse manager makes this comment: When you all can come to a decision, let me know and well move on from there. This leader is best identified as which of the following? 1. Democratic leader 2. Permissive leader 3. Bureaucratic leader 4. Situational leader 2. Permissive leader A nurse manager allows the staff members to make their own schedules and do their own client assignments on their shifts. However, during a code situation, the nurse manager will make decisions for the staff by instructing which nurse to assume which responsibility. This manager is exemplifying which style of leadership? 1. Permissive 2. Democratic 3. Situational 4. Bureaucratic 3. Situational A group of community health nurses work together in the same office. They are each responsible for their own caseloads and scheduling of appointments. Their major leadership directives come from the state health office, several hundred miles away. This group of nurses is functioning under what type of leadership? 1. Charismatic 2. Shared 3. Transformational 4. Transactional 2. Shared A charge nurses responsibilities include the day-to-day management and coordination of therapies for the clients, client assignments, and scheduling. Which type of management is the charge nurse performing? 1. Top level 2. Middle level 3. First level 4. Upper level 3. First level A nurse manager is working on new job descriptions for all nursing units of the hospital. Which management function is this nurse conducting? 1. Planning 2. Organizing 3. Directing 4. Coordinating 2. Organizing A hospital was named in a lawsuit after a client had to undergo a second surgical procedure because an arthroscopy was performed on the wrong knee during surgery. The hospital settled out of court with the client for damages. This is an example of which principle of management? 1. Authority 2. Responsibility 3. Coordination 4. Accountability 4. Accountability A nurse manager has had to handle a particularly difficult physician who is demanding as well as demeaning. Through this situation, the nurse manager has learned that accuracy and honesty are attributes of which skill necessary for managers? 1. Critical thinking 2. Communication 3. Networking 4. Responsibility 2. Communication A nursing student would like to do an observation on one of the inpatient units at a hospital. In assisting the student to meet this desire, the educator would look for which type of nurse? 1. Mentor 2. Manager 3. Team leader 4. Preceptor 4. Preceptor A hospital is implementing a computerized charting system, and all nursing staff is required to be oriented to the system by a specific deadline. Which type of change is occurring with the staff? 1. Overt change 2. Covert change 3. Unplanned change 4. Drift 1. Overt change The nursing staff is informed that the current system of record keeping is going to be changed to make it more efficient. In which stage of change is the nursing staff? 1. Refreezing 2. Unfreezing 3. Moving 4. Drift 2. Unfreezing Prior to delegating a task, the nurse reviews the rights of delegation; these include which rights? Standard Text: Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. Time 5. Task 1. Supervision 2. Evaluation 5. Task The nurse has been promoted to the role of manager for a client care area. What responsibilities of the nurse will this new role include? Standard Text: Select all that apply. 1. Accomplish the goals of the organization. 2. Use the organizations resources efficiently. 3. Ensure effective client care. 4. Ensure compliance with regulatory standards. 5. Manage relationships. 1. Accomplish the goals of the organization. 2. Use the organizations resources efficiently. 3. Ensure effective client care. 4. Ensure compliance with regulatory standards. A nurse is identified as being an effective leader. With this designation, the nurse will most likely demonstrate which characteristics? Standard Text: Select all that apply. 1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others 5. Focus on systems 1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others A staff nurse has been identified by others as being an effective leader. With this designation, the nurse implements which principles? Standard Text: Select all that apply. 1. Vision 2. Influence 3. Serve as a role model 4. Planning 5. Organizing 1. Vision 2. Influence 3. Serve as a role model The nurse is reviewing feedback from other staff members on leadership behaviors. Which characteristics are consistent with being an effective leader? Standard Text: Select all that apply. 1. Energetic 2. Creative 3. Optimistic 4. Open 5. Risk taking 1. Energetic 2. Creative 3. Optimistic 4. Open The nurse has been promoted to a position that includes the supervision of first-level management and responsibility for activities in a specific department. This nurse will most likely have which title? Standard Text: Select all that apply. 1. Supervisor 2. Nurse manager 3. Head nurse 4. Primary care nurse 5. Vice president 1. Supervisor 2. Nurse manager 3. Head nurse The nurse practices responsibility when functioning in the role of manager of a care area. What will the nurse manager demonstrate as evidence of responsibility? Standard Text: Select all that apply. 1. Effective utilization of resources 2. Communication to subordinates 3. Implementation of organizational goals and objectives 4. Problem solving 5. Managing the work team 1. Effective utilization of resources 2. Communication to subordinates 3. Implementation of organizational goals and objectives 4. Problem Solving The nurse is determining whether an activity can be delegated to a UAP. What will the nurse use to make this determination? Standard Text: Select all that apply. 1. Determine whether it is the right task. 2. Determine whether it is under the right circumstances. 3. Determine whether it is to the right person. 4. Determine the type of communication. 5. Determine whether there is enough time. 1. Determine whether it is the right task. 2. Determine whether it is under the right circumstances. 3. Determine whether it is to the right person. 4. Determine the type of communication. The manager identifies a staff nurse to serve as a change agent for the implementation of a computerized documentation system. What attributes did the manager observe to designate the staff nurse to have this role? Standard Text: Select all that apply. 1. Self-confident 2. Skilled in teaching 3. Hesitant with decision making 4. Excellent communication skills 5. Effective utilization of resources 1. Self-confident 2. Skilled in teaching 4. Excellent communication skills 5. Effective utilization of resources The manager determines that a new graduate nurse needs additional training on the principles of delegation. What delegation to unlicensed assistive personnel did the manager observe to make this decision? Standard Text: Select all that apply. 1. Bathing a patient recovering from surgery 2. Weighing a patient who is prescribed diuretics 3. Discharge instruction teaching 4. Transferring and ambulating a client after hip replacement surgery 5. The care of an intravenous access device 3. Discharge instruction teaching 5. The care of an intravenous access device The nurse is providing care within the total care context. What should the nurse consider when using this care approach? 1. The individualism of the client 2. Principles applicable to the client at this moment 3. Principles general to all clients of the same age and condition 4. The persons self-identity 3. Principles general to all clients of the same age and condition The nurse is practicing the concept of holism with a client. Which action is the nurse most likely making? 1. Considering how the loss of a clients job will affect the regulation of the clients diabetes 2. Making sure to do complete teaching regarding pharmacological interventions 3. Following physician treatments on schedule 4. Prioritizing the needs of the client assigned according to Maslows hierarchy 1. Considering how the loss of a clients job will affect the regulation of the clients diabetes Psychologic homeostasis is maintained by a variety of mechanisms. Which client should the nurse identify as being the most likely candidate to obtain psychologic homeostasis? 1. A child who is used to getting ready for school alone 2. A teenager whose circle of friends includes single parents of the same age 3. An elderly person who has just moved to a long-term care facility 4. A young adult who is in a long-term relationship 4. A young adult who is in a long-term relationship A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslows human needs theory, at which level should the nurse recognize that the client is struggling? 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-esteem 4. Self-esteem A client is hospitalized with numerous acute health problems. According to Maslows basic needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client? 1. Risk for Injury related to unsteady gait 2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients 3. Self-Care Deficit related to weakness and debilitation 4. Powerlessness related to chronic disease state 2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients The nurse is using Kalishs adaptation of Maslows hierarchy of needs when planning client care. Which client should the nurse identify as exhibiting a level of Kalishs adaptation? 1. Has a homosexual encounter for the first time 2. Has a need to participate in school sports and be on the team 3. Strives to become the CEO of a company 4. Is sleep deprived because of musculoskeletal discomfort 1. Has a homosexual encounter for the first time The nurse is reviewing the Healthy People 2020 information which should the nurse identify as the foundation for this initiative? 1. Individual and community health are closely linked 2. The government is responsible for individual health 3. Businesses have no role in the health of the communities 4. Communities should expect local organizations to pay for healthcare 1. Individual and community health are closely linked A client comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This client is modeling which behavior? 1. Health promotion 2. Health protection 3. Tertiary prevention 4. Primary prevention 2. Health protection A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor? Standard Text: Select all that apply. 1. Time management 2. Healthy eating habits 3. Exercise after stroke 4. Bicycle safety for children 5. Performing self-examination of the breasts 1. Time management 2. Healthy eating habits 4. Bicycle safety for children A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions? 1. Interpersonal influences 2. Perceived benefits of action 3. Situational influences 4. Perceived self-efficacy 2. Perceived benefits of action A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behavior-specific cognitions should the nurse focus to assist this client with success in the rehabilitation program? 1. Situational influences 2. Perceived benefits of action 3. Perceived barriers to action 4. Interpersonal influences 4. Interpersonal influences A client is learning how to manage his asthma. In providing teaching, the nurse stresses the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior? 1. Competing preferences 2. Competing demands 3. Situational influences 4. Interpersonal influences 1. Competing preferences Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and determine that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying? 1. Termination stage 2. Preparation stage 3. Contemplation stage 4. Action stage 3. Contemplation stage A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which stage of health behavior change? 1. Termination stage 2. Maintenance stage 3. Contemplation stage 4. Action stage 4. Action stage The health nurse of a busy university campus is implementing a health promotion activity by placing posters about proper hand washing in all of the public restrooms on campus. Which type of health promotion program is the nurse implementing? 1. Environmental control 2. Information dissemination 3. Health risk appraisal and wellness assessment 4. Lifestyle and behavior change 2. Information dissemination The nurse is preparing information packets for incoming college students regarding sexually transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this situation, the nurse has assumed which role? 1. Facilitator 2. Advocate 3. Teacher 4. Coordinator of services 3. Teacher The nurse suggests that a client make a list of past experiences that have brought joy, peace, and hope into the clients life. What action is the nurse assisting the client to complete? 1. Lifestyle assessment 2. Social support systems review 3. Health beliefs review 4. Spiritual health assessment 4. Spiritual health assessment A client has received a high score on the Life-Change Index. For which part of the clients assessment should the nurse use this information? 1. Life stress review 2. Social support systems review 3. Lifestyle assessment 4. Health beliefs review 1. Life stress review The client is a high school student who is also a single parent. She is attending parenting classes while studying full time and living in an apartment with her child. The student also meets twice a week with a teen peer group and participates in a nutrition program through the county. Which is the most appropriate diagnosis for this client? 1. Risk for Situational Low Self-Esteem 2. High Risk for Caregiver Role Strain 3. Readiness for Enhanced Coping 4. Readiness for Enhanced Nutrition 3. Readiness for Enhanced Coping The nurse educator provides developmental testing for kindergarten through thirdgrade students. Which level of prevention is the nurse performing? 1. Primary 2. Secondary 3. Tertiary 4. Community 2. Secondary A client has had a severe brain injury and has been in a rehabilitation hospital for several months. Recently, the client developed pneumonia and is currently on intravenous antibiotic therapy. Which level of prevention should the nurse use to address the health problem of pneumonia? 1. Primary 2. Secondary 3. Tertiary 4. Acute 2. Secondary A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration? 1. Rest and exercise 2. Adjusting to physiologic changes and limitations 3. High obesity percentages 4. Safety promotion and injury prevention 2. Adjusting to physiologic changes and limitations A nurse is working with various cultures while implementing health promotion activities for the community center. Bringing the minister of the church into the planning stage of these activities would be sensitive to which cultural groups? 1. Latino American 2. Asian American 3. Native American 4. African American 4. African American The nurse is reviewing the characteristics of homeostatic mechanisms prior to assessing a client. Which characteristics should the nurse keep in mind during this assessment? Standard Text: Select all that apply. 1. They are self-regulating. 2. They are compensatory. 3. They are regulated by negative feedback systems. 4. They can require several feedback mechanisms to correct only one physiologic imbalance. 5. They are related to a closed system. 1. They are self-regulating. 2. They are compensatory. 3. They are regulated by negative feedback systems. 4. They can require several feedback mechanisms to correct only one physiologic imbalance. The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurses advocacy? Standard Text: Select all that apply. 1. Participating in a community-focused 5-mile run. 2. Attending the local high schools football games. 3. Providing an educational program to senior citizens on blood pressurecontrol strategies. 4. Attending a community meeting that is promoting the creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques. 1. Participating in a community-focused 5-mile run. 3. Providing an educational program to senior citizens on blood pressurecontrol strategies. 4. Attending a community meeting that is promoting the creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques. The nurse is reviewing information collected while providing client care. Which findings should the nurse identify as being a homeostatic mechanism? Standard Text: Select all that apply. 1. The clients heart rate increases when walking up a flight of stairs. 2. The client shivers when core body temperature drops. 3. A childs bone growth occurs in spurts. 4. Decreased secretion of insulin occurs when food is not ingested. 5. Lactation occurs in a pregnant woman. 1. The clients heart rate increases when walking up a flight of stairs. 2. The client shivers when core body temperature drops. 4. Decreased secretion of insulin occurs when food is not ingested. The nurse is structuring activities that take a client's developmental stage into consideration. Which activities should the nurse include? (Select all that apply.) 1. Implementing seizure precautions 2. Creating a schedule for daily wound care 3. Monitoring intake, output, and daily weights 4. Preparing newborn care classes for new parents 5. Scheduling instruction sessions on self-administration of insulin 4. Preparing newborn care classes for new parents 5. Scheduling instruction sessions on self-administration of insulin The nurse reviews the progress of leading health indicators as identified by Healthy People 2020. Which indicator has been met? (Select all that apply.) 1. Oral health 2. Mental health 3. Injury and violence 4. Environmental quality 5. Maternal, infant, and child health 3. Injury and violence 4. Environmental quality 5. Maternal, infant, and child health The nurse is asked to explain the difference between health promotion from health protection. Which information should the nurse include in the response? 1. Health protection activities focus on improving overall health. 2. Health promotion activities focus on reducing the risk of disease. 3. Health protection must address physical and social situations that cause poor health. 4. Health promotion must address physical and social situations that cause poor health. 4. Health promotion must address physical and social situations that cause poor health. The nurse is planning a community program to promote health. Which topics should the nurse consider for this program? (Select all that apply.) 1. Information dissemination 2. Medication teaching sessions 3. Lifestyle and behavior change 4. Environmental control programs 5. Health risk appraisal and wellness assessment 1. Information dissemination 3. Lifestyle and behavior change 4. Environmental control programs 5. Health risk appraisal and wellness assessment The nurse cares for clients in a community health clinic. Which action should the nurse take to support health promotion when providing client care? (Select all that apply.) 1. Teach client self-care strategies 2. Reinforce health-promoting behaviors 3. Guide clients with effective problem solving 4. Educate clients to be effective healthcare consumers 5. Contact the healthcare provider for a medication prescription 1. Teach client self-care strategies 2. Reinforce health-promoting behaviors 3. Guide clients with effective problem solving 4. Educate clients to be effective healthcare consumers A client desires to make a health behavior change but needs to "see what it looks like" when someone else does it. Which should the nurse suggest to serve as a model for the client's behavior change? 1. A movie star 2. A sports figure 3. A family healthcare provider 4. A person who the client respects 4. A person who the client respects A client is attending classes on building positive relationships with significant others as well as learning skills to be open-minded and respectful to those whose opinions are different. The nurse realizes that this client is focusing on which component of wellness? 1. Physical 2. Social 3. Emotional 4. Environment 2. Social The nurse is assisting a client and his family after the client had a stroke and is no longer able to return to his previous employment. The nurse has made a referral to vocational rehabilitation for assistance in retraining the client in a different occupation. With which component of wellness is the nurse assisting this client? 1. Intellectual 2. Environmental 3. Occupational 4. Emotional 3. Occupational A nurse educator is explaining the concept of health and parallels this with interruption of body systems and symptoms of disease or injury. This educator is interpreting health according to which model? 1. Health-illness continua 2. Eudemonistic 3. Adaptive 4. Clinical 4. Clinical A nurse is working in a rehabilitation center with a client who had a serious injury. Part of the client's care plan includes working on coping with her current limitations since the injury. This nurse is working within which model of health? 1. Role performance 2. Adaptive 3. Eudemonistic 4. Clinical 2. Adaptive A nurse is conducting a community assessment to determine which diseases are prevalent and most likely to occur. The nurse is basing the assessment on which model of health? 1. Role performance 2. Eudemonistic 3. Ecological 4. Adaptive 3. Ecological A nurse is assessing a client who practices yoga for relaxation, is following a nutritionally sound diet, and has supportive, sound relationships with her spouse and children. According to Dunn's high-level wellness grid, this client would exemplify which health characteristic? 1. Emergent high-level wellness in a favorable environment 2. Emergent high-level wellness in an unfavorable environment 3. Protected health in a favorable environment 4. High-level wellness in a favorable environment 4. High-level wellness in a favorable environment A nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do not have access to health care and live in poverty. According to Dunn's high-level wellness grid, the nurse will be working with clients in which quadrant? 1. Emergent high-level wellness in an unfavorable environment 2. Protected poor health in a favorable environment 3. Poor health in an unfavorable environment 4. Protected poor health in an unfavorable environment 3. Poor health in an unfavorable environment The nurse educator is reviewing internal variables that affect people's health status. On which variables is this nurse focusing? Standard Text: Select all that aply. 1. Genetic makeup 2. Age 3. Developmental level 4. Environment 5. Spiritual and religious beliefs 1. Genetic makeup 2. Age 3. Developmental level 5. Spiritual and religious beliefs: An occupational health nurse is surveying employees. Which employee should the nurse identify as being predisposed to an illness? 1. An employee who is in a middle-management position and takes stress from administration as well as the employees 2. An employee who works in the janitorial department 3. An employee who works 12-hour days, 3 days a week 4. An employee who works 4 days on and 3 days off 1. An employee who is in a middle-management position and takes stress from administration as well as the employees A community health nurse is testing the theory of locus of control (LOC). Which client demonstrates the internal control concept of this theory? 1. A client who takes an active role in all health decisions 2. A client who allows the primary care provider to make all the decisions 3. A client who does not make any decisions without his or her spouse's input 4. A client who relies on information from the local hospital for his or her health needs 1. A client who takes an active role in all health decisions The nurse case manager is concerned about a particular client being discharged from the hospital. Which factors should alert the nurse to possible problems with this client's adherence to treatment? 1. The prescribed therapy is costly and of unknown duration. 2. The therapy will require no lifestyle changes of the client. 3. The client has not had difficulty understanding the regimen. 4. The client's culture is supportive of Western medicine. 1. The prescribed therapy is costly and of unknown duration. During a home visit with a new community member, the nurse suspects that a client has a chronic illness. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Experienced symptoms for 8 months 2. Has periods where the symptoms disappear 3. Altered activities of daily living because of the illness 4. Problem disappeared with over-the-counter medication 5. Symptoms appeared abruptly and disappeared after treatment 1. Experienced symptoms for 8 months 2. Has periods where the symptoms disappear 3. Altered activities of daily living because of the illness The nurse determines that an older client is in the medical care contact stage of an illness. What did the client demonstrate to cause the nurse to make this decision? Standard Text: Select all that apply. 1. The client asked if the illness can be treated or recovery is possible. 2. The client asked if the symptoms experienced are a part of an illness. 3. The client asked if the symptoms can be explained in plain language. 4. The client stated that the illness is not acceptable and wants a second opinion. 5. The client stated that treatment is accepted and will be completed as identified. 1. The client asked if the illness can be treated or recovery is possible. 2. The client asked if the symptoms experienced are a part of an illness. 3. The client asked if the symptoms can be explained in plain language. 4. The client stated that the illness is not acceptable and wants a second opinion. A client describes self as being healthy despite having several chronic illnesses. In which way should the nurse interpret the client's statement about health? 1. The client is in denial 2. The client is delusional 3. The client has a different perception of health 4. The client has no idea of the extent of the illnesses 1. The client is in denial A client has not been adhering to a previously agreed-upon plan to improve health. Which action should the nurse take? (Select all that apply.) 1. Reinforce teaching 2. Demonstrate caring 3. Provide positive reinforcement 4. Report to the healthcare provider 5. Establish a therapeutic relationship 1. Reinforce teaching 2. Demonstrate caring 3. Provide positive reinforcement 5. Establish a therapeutic relationship A client is seeking medical attention for an acute illness. Which right does the client have when assuming the sick role? 1. The client must seek competent help. 2. The client believes something is wrong. 3. The client has to get well as soon as possible. 4. The client is not responsible for the health problem. 4. The client is not responsible for the health problem. A client with an acute illness is observed washing dishes and making the bed. Which stage of the illness is this client demonstrating? 1. Recovery 2. Medical care contact 3. Symptom experience 4. Dependent client role 1. Recovery The nurse visits the home of a client with a chronic illness. For which factor should the nurse assess to determine the impact of the client's illness on the family? (Select all that apply.) 1. Seriousness of the illness 2. Length of time of the illness 3. Change in the client's lifestyle 4. Cultural customs of the family 5. Member of the family who is ill 1. Seriousness of the illness 2. Length of time of the illness 4. Cultural customs of the family 5. Member of the family who is ill Which statement, made by the client, would indicate a me-centered self-concept? 1. I couldnt stand to disappoint my parents. 2. My sister is so much smarter than I am. 3. My future is based on the decisions I make today. 4. The world has always been against people like me. 3. My future is based on the decisions I make today. The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses self-concept along with information to use with clients. Why is the information for nurses important? 1. The nurses self-concept is more important than the clients. 2. Poor self-concept is the number-one reason for nursing burnout. 3. Nurses with positive self-concept are better able to help clients. 4. Nurses with poor self-concept are more likely to make errors. 3. Nurses with positive self-concept are better able to help clients. The newly graduated nurse is working with a mentor who has been a nurse for 25 years. The mentor tells the new graduate, I learn something new about nursing every day. What does this indicate about the mentors self-awareness? 1. This nurse is not very self-aware. 2. The mentors self-awareness is behind normal development. 3. Because this mentor has been a nurse for so long, self-awareness is no longer an important issue. 4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior. 4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior. The adolescent male client who weighs 100 is considering taking some herbal stuff to increase muscle mass and strength. The nurse should interpret this statement as an indication that this client has 1. a strong need for admiration. 2. serious problems with logical thinking. 3. incongruence between reality and ideal self. 4. the need for referral to a psychologist. 3. incongruence between reality and ideal self. During an assessment, the nurse notes that a client frequently refers to his Native American heritage. The nurse determines that this heritage is a strong part of the clients 1. personal identity. 2. body image. 3. role performance. 4. self-esteem. 1. personal identity. A client who has recently lost 75 pounds continues to dress in loose, baggy clothing and frequently talks about being fat. The nurse realizes this finding most likely indicates 1. role confusion. 2. body image disturbance. 3. fear of success. 4. lack of education. 2. body image disturbance. A rare malignancy will require the amputation of an adolescent clients leg. The client refuses the surgery, stating: I would rather die than have my leg amputated. What information should the nurse use to plan future interventions for this client? 1. The knowledge that adolescents are very concerned about body image 2. Concern about need for education regarding the danger of delaying surgery 3. The fact that the parents will have the ultimate decision about surgery 4. The ability of the adolescent to understand medical terminology 1. The knowledge that adolescents are very concerned about body image Which statement made by a new mother would indicate to the nurse that there is potential for lowered self-esteem due to role ambiguity? 1. I dont know if I know how to be a mom. 2. My husband will be a stay-at-home dad while I work. 3. Im so disappointed that this baby is not a girl. 4. I havent even finished the babys room. 1. I dont know if I know how to be a mom. The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern? Standard Text: Select all that apply. 1. I hate my hair. 2. Life is wonderful! 3. My hips are too big. 4. I wish I had that nose job 2 years ago. 5. It is awesome that I got that promotion at work. 1. I hate my hair. 3. My hips are too big. 4. I wish I had that nose job 2 years ago. Which nursing intervention would be helpful when caring for a client who has negative self esteem? 1. Find a way to praise the client during each encounter. 2. Design a series of small successes for the client. 3. Correct the client when negativity arises. 4. Tell the client how much easier life would be with positive self-esteem. 2. Design a series of small successes for the client. The nurse is conducting a thorough psychosocial assessment of a client who presents with complaints of fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment? 1. Take detailed notes to record client responses. 2. Ask as many questions as possible to explore all areas of concern. 3. Start the interview by asking a series of yes/no questions. 4. Investigate the clients culture prior to the interview. 4. Investigate the clients culture prior to the interview. Which statement should the nurse make first when assessing a clients self-concept? 1. Describe yourself as a person. 2. Tell me about your family. 3. Describe what you do when you have free time. 4. Tell me about the work you do. 1. Describe yourself as a person. During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take about the clients reluctance to share information? 1. Document that the client is not cooperative. 2. Consider any cultural implications of these actions. 3. Assume that the client has something to hide. 4. Ask another nurse to sit in on the next interview attempt. 2. Consider any cultural implications of these actions. Which characteristic of self-esteem will make it difficult for the nurse to plan interventions for a client? 1. Low motivation to improve 2. A focus on problems 3. Expressed disinterest in working on improvement 4. Not satisfied with personal situation 2. A focus on problems The nurse is assisting a client in setting goals as a strategy to reinforce strengths. What intervention should the nurse employ? 1. Encourage the client to set attainable goals, even if small. 2. Help the client choose a significant goal, even if it is time consuming. 3. Devise a set of goals from which the client can pick. 4. Advise the client to avoid goals that will require too much effort. 1. Encourage the client to set attainable goals, even if small. The nurse and client had set the following expected outcome: At the next clinic visit, the client will report participation in three activities to increase self-esteem. At todays visit, the client is unable to meet the stated outcome. What should be the nurses next action? 1. Explore the possible reasons for not meeting the outcome. 2. Reevaluate the accuracy of the outcome statement. 3. Collaborate with the client to write a new expected outcome. 4. Identify new interventions to help the client achieve the outcome. 1. Explore the possible reasons for not meeting the outcome. The spouse tells the nurse that the client is not making progress in developing a more positive self-esteem. What should the nurse respond to the spouse? 1. Most clients make quicker progress. 2. Self-esteem work takes time and is not easily evaluated. 3. What have you done to help the client with this work? 4. Do you think that the client is really trying? 2. Self-esteem work takes time and is not easily evaluated. The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included? 1. If the baby awakens at night, let him cry for a few minutes before responding. 2. Keep the baby on a 3-hour feeding schedule, even if it means awakening him. 3. Respond to the babys needs promptly and consistently. 4. Use firm, loving discipline with the baby from the beginning. 3. Respond to the babys needs promptly and consistently. The parents tell the nurse that their preschooler demands to wear specific clothing. They are concerned that the day-care workers might think they are negligent because the preschooler often wears mismatched clothing. What should be the nurses response to this concern? 1. Dont worry, day-care workers are accustomed to that sort of thing. 2. This is normal and the preschooler is just practicing skills needed later in life 3. I am glad you brought that to our attention. I will make a note for her pediatrician. 4. You should have better control of the child now if you have any hope of controlling the child during the teenage years. 2. This is normal and the preschooler is just practicing skills needed later in life The parents of an adolescent report that their child has recently gotten into trouble at school for cheating on an examination and has been barred from participating in a school trip as a consequence of that action. They ask for the nurses professional opinion about the suitability of the punishment. Which answer best supports self-esteem development in this adolescent? 1. I think the punishment may be excessive. Have you talked with the school officials about the incident? 2. Because my expertise is in health, I really cant respond to your question. 3. Honesty and respect for authorities is important. I am surprised that the punishment is not more extensive. 4. Living with the consequences of your actions is a way to help the adolescent develop good self-esteem. 4. Living with the consequences of your actions is a way to help the adolescent develop good self-esteem. The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self-esteem. What intervention would be appropriate for this resident? 1. Ask the resident for advice in setting up an activity in the dayroom. 2. Keep the resident too busy to dwell in the past. 3. Dont allow the resident to talk about minor concerns. 4. Meet with the social worker to plan all of the clients care. 1. Ask the resident for advice in setting up an activity in the dayroom. The nurse is planning to assess a clients family relationships. What questions should the nurse ask to obtain this information? Standard Text: Select all that apply. 1. How do you spend your free time? 2. What is your home like? 3. Who is most important to you? 4. How well do you feel you accomplish what is expected of you? 5. Whom do you seek out for help? 2. What is your home like? 4. How well do you feel you accomplish what is expected of you? A client tells the nurse that her spouse expects the client to maintain the home and children as well as have a job to help with household expenses. The client is demonstrating fatigue and inadequacy. The nurse identifies which nursing diagnosis as appropriate for the client at this time? 1. Chronic Low Self-Esteem 2. Ineffective Role Performance 3. Disturbed Body Image 4. Parental Role Conflict 2. Ineffective Role Performance A client recovering from a lumpectomy for breast cancer tells the nurse that she feels ugly. For which nursing diagnosis should the nurse plan interventions? 1. Powerlessness 2. Social Isolation 3. Grieving 4. Hopelessness 3. Grieving An adult client who has been a successful writer in the past has been experiencing low self esteem over the last year. Which behaviors indicate that the client is attempting to make positive changes? Standard Text: Select all that apply. 1. The client joined a library book club. 2. The client counted the number of rejection letters she received from publishers. 3. The client states that she no longer reads Facebook to compare her life with her friends lives. 4. The client works with the local Wheels on Meals to deliver meals once a week to older community members. 5. The client shared a letter from a magazine publisher that is going to print her short story in the next edition 1. The client joined a library book club. 3. The client states that she no longer reads Facebook to compare her life with her friends lives. 4. The client works with the local Wheels on Meals to deliver meals once a week to older community members. 5. The client shared a letter from a magazine publisher that is going to print her short story in the next edition A client speaks about an adult son who is a practicing homosexual and expresses concern by stating: I am so worried about him and I know he is going to hell. What is the most important fact for the nurse to consider in formulating a response to this clients concern? 1. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved. 2. Because alternative lifestyles are now so well accepted in society, this parent should not feel so much concern. 3. What constitutes normal sexual expression varies among cultures and religions. 4. Sexual development is genetically determined and not affected by environment. 3. What constitutes normal sexual expression varies among cultures and religions. The parent of a 20-month-old is very concerned because the baby touches the genital area during diaper changes. How should the nurse respond to this concern? 1. At 20 months this touching is not a sexual experience. 2. Masturbation to orgasm is common and normal at this age. 3. Genital stimulation should not be occurring until the age of 2 1/2 or 3. 4. Babies are sexual beings, but this activity should be discouraged. 1. At 20 months this touching is not a sexual experience. The nurse is teaching a class on body development to a group of middle school girls. One of the girls asks about using tampons for sanitary protection during menstruation. What advice should the nurse include? 1. Tampons should not be used until the menstrual cycle is well established, usually 2 to 3 years after the first period occurs. 2. Superabsorbent tampons should be used at night to protect from overflow accidents. 3. Tampons should be alternated with sanitary pads to help decrease risk for infection. 4. Tampons should be changed at least every 8 hours. 3. Tampons should be alternated with sanitary pads to help decrease risk for infection. The nurse is developing strategies for the relief of menstrual cramping to teach a group of young clients. What should be the focus of these strategies? 1. Increase of blood flow to the uterine muscle 2. Avoidance of uterine contraction 3. Minimization of menstrual flow 4. Decrease in estrogen production 1. Increase of blood flow to the uterine muscle During a routine physical, an 11-year-old tells the nurse that many students in school are doing it. How should the nurse respond to this statement? 1. Tell the client to talk with parents about sexual matters. 2. Ask what doing it means to this client. 3. State that sexual activity is not appropriate at age 11. 4. Stay silent and wait for the client to continue the discussion. 2. Ask what doing it means to this client. A young adult single mother of a second-grade child has to make a decision regarding the teacher her child will have in third grade and asks the nurse for advice. All other variables being equal, which choice is best? 1. A woman with 35 years of teaching experience 2. A man who is 40 years old 3. A newly graduated 22-year-old man 4. A 30-year-old woman 2. A man who is 40 years old Which statement made by a postmenopausal client should the nurse evaluate as indicating the need for further assessment? 1. For some reason, I have more sexual desire than ever. 2. I use water-soluble lubricant to treat my vaginal dryness. 3. I am so glad that I dont need to worry about sex anymore. 4. Sex certainly takes longer than it used to, but Im getting used to that. 3. I am so glad that I dont need to worry about sex anymore. A research article the nurse is reading discusses the prevalence of androgyny in persons 20 to 30 years old. What should the nurse keep in mind when caring for clients who are androgynous? 1. They do not limit behaviors to one gender over the other. 2. They are attracted to people of the same gender. 3. They often repress their sexual feelings. 4. They hold rigid stereotyped gender role expectations. 1. They do not limit behaviors to one gender over the other. A client experienced female circumcision as a puberty ritual while living in Africa as a child. For which health problem should the nurse monitor the client as an adult? 1. Early menopause 2. Increased menstrual flow 3. Chronic urinary tract infection 4. Tendency for postpartum hemorrhage 3. Chronic urinary tract infection The 45-year-old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How should the nurse interpret this assessment data? 1. This couple is experiencing sexual dysfunction. 2. The womans lack of sexual desire has resulted in impotence in her husband. 3. If both partners share the same lack of desire, there is often not a problem. 4. This situation is so unnatural that some dysfunction is present. 3. If both partners share the same lack of desire, there is often not a problem. A client is concerned because he was unable to achieve an erection during his last sexual encounter with his wife. He tells the nurse that he has worried about becoming impotent because he had a sexually transmitted infection as a young adult. What is the nurses best response to this clients concerns? 1. Sexually transmitted infections may result in sexual problems in adults. 2. Erectile dysfunction is the correct term for the inability to achieve or sustain an erection. 3. An occasional incident like this is normal and common and there is no reason to be concerned. 4. The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions. 3. An occasional incident like this is normal and common and there is no reason to be concerned. The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed with vaginismus. What equipment should the nurse obtain for this examination? 1. Culture tubes to assess expected vaginal infection 2. Extra cleaning supplies to remove thick external secretions 3. Smaller-than-normal vaginal speculums 4. Equipment for preexamination douche 3. Smaller-than-normal vaginal speculums There is disagreement among the nursing unit staff regarding how much sexual history should be included in adult admission assessments. What standard is generally the most applicable? 1. A complete sexual history must be included in the admission history and physicals. 2. Sexual information should be pursued only if the clients chief complaint indicates possible sexual dysfunction. 3. Sexual assessment should be done by the physician and not repeated by the nurse. 4. The amount of sexual information taken will vary on a case-by-case basis. 4. The amount of sexual information taken will vary on a case-by-case basis. The mother of a 5-year-old tells the nurse that her daughter has always been closer to her than to her husband. The mother expresses concern that, over the last 2 months, the little girl wants to spend all of her time with her father instead of with the mother. The nurse recognizes that this behavior 1. may indicate sexual abuse by the father and should be further investigated. 2. is a normal expectation of a preschooler developing sexuality. 3. indicates that the girl is overidentifying with the male gender. 4. can be a sign of precocious puberty and should be monitored. 2. is a normal expectation of a preschooler developing sexuality. A recently married couple is trying to conceive a child. The husband is a collegiate athlete and his coach forbids sexual activity for 2 days prior to a game. The wife asks the nurse if abstinence before the game is necessary. What is the best response? 1. As long as intercourse is not involved, there is no reason to avoid sexual activity. 2. Some residual physical weakness is common for up to 18 hours after sex. 3. This is a common myth among athletes, but there is no basis in fact. 4. In fact, sexual activity before intense physical exercise increases stamina and endurance. 3. This is a common myth among athletes, but there is no basis in fact. The 15-year-old female tells the nurse that she makes her boyfriend stop intercourse before she has an orgasm so she will not get pregnant. What teaching is necessary for this client? 1. Even though she doesnt get pregnant, she might still get a sexually transmitted infection. 2. Intercourse until orgasm may actually reduce conception because the vaginal contractions help to expel sperm. 3. Conceiving is not related to whether or not the female partner experiences an orgasm. 4. As long as her boyfriend does not ejaculate in her vagina, conception is unlikely. 3. Conceiving is not related to whether or not the female partner experiences an orgasm. The high school student tells the school nurse that during biology the class learned that alcohol is associated with erectile dysfunction. The student wonders why so many girls get pregnant during evenings when alcohol is consumed. The nurse should plan a response based upon which concept? 1. Alcohol is a central nervous system depressant that affects judgment. 2. Erectile dysfunction only occurs after years of alcohol abuse. 3. Alcohol is a sexual stimulant. 4. Erectile dysfunction occurs only in men older than 50. 1. Alcohol is a central nervous system depressant that affects judgment. The female client has experienced recurrent candidiasis with intense vaginal itching and excoriation. After treatment the client is reexamined, and the nurse practitioner finds presence of a white, cheesy discharge. What recommendation is necessary? 1. Referral to a surgeon for excision of infected tissue 2. Examination and treatment of sexual partner 3. Treatment with a stronger oral antibiotic 4. Routine douches with a topical antibiotic solution 2. Examination and treatment of sexual partner The nurse enters the room and finds the adult client masturbating. What action should the nurse take? 1. Tell the client that masturbation is harmful to sexual well-being. 2. Say excuse me and leave the room. 3. Request that the client stop so that care can be provided. 4. Ask the client if there are any sexual concerns that should be discussed. 2. Say excuse me and leave the room. A nurse colleague learns that a grandchilds day-care center is planning a class on sexuality for 3- and 4-year-olds. Discussion of this plan should include what concept? 1. At this age, education regarding sexuality should come from parents. 2. Children are sexual beings from before birth. 3. Understanding the body and sexuality are a part of growth and development. 4. Sexual activity is beginning at earlier and earlier ages. 1. At this age, education regarding sexuality should come from parents. In discussion with teenagers, the nurse chooses to use the term sexually transmitted infection rather than sexually transmitted disease. What is the rationale for this choice? 1. Infection is a much more precise term for the transmission that occurs. 2. The word disease may elicit guilt, shame, and fear in the client. 3. Sexually transmitted disease does not receive as much third-party reimbursement as does sexually transmitted infection. 4. These terms can be used interchangeably and there is no good rationale for using one over the other. 2. The word disease may elicit guilt, shame, and fear in the client. The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the P section of this format? 1. Ask the physician for permission to discuss sexual topics with the client. 2. Obtain signed informed consent from both the client and the spouse or partner prior to providing them with sexual information. 3. Acknowledge the clients spoken and unspoken sexual concerns when providing care. 4. Document precertification for benefits from the clients insurance company regarding sexual teaching. 3. Acknowledge the clients spoken and unspoken sexual concerns when providing care. The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format? 1. In order to avoid causing anxiety, limit the amount of information given to clients regarding adverse sexual side effects of treatments or medications. 2. Give the client accurate but concise information in regard to any sexual questions that might be asked. 3. State information using slang terms to refer to sexual body parts because the client is not likely to know the proper terms. 4. Review current research literature associated with the sexual concerns of the client and partner. 2. Give the client accurate but concise information in regard to any sexual questions that might be asked. The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the SS section of this format? 1. Use the nurses knowledge about how disease affects sexuality to offer specific suggestions for the client. 2. Focus interventions on explaining the somatic sexual difficulties and their treatment. 3. Offer the client a list of expected sexual side effects of drugs or treatments. 4. Identify any concerns the client has regarding attraction to the same sex. 1. Use the nurses knowledge about how disease affects sexuality to offer specific suggestions for the client. The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the IT section of this format? 1. Use information technology such as the Internet to obtain guidance suggestions for the client. 2. Use the technique of informal therapeutic groups to assist the client and partner. 3. Evaluate previous interventions and treatment for success. 4. Recommend intensive therapy with a qualified sex therapist. 4. Recommend intensive therapy with a qualified sex therapist. The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident (stroke) express concern that their father is always exposing and playing with himself and his catheter while they are in the room. Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurses priority action? 1. Tell the client to keep his hands away from his penis. 2. Assess the clients penis for irritation from the catheter. 3. Ask the client to keep his linens at waist level when he has visitors. 4. Collaborate with the physician regarding medications to control this behavior. 2. Assess the clients penis for irritation from the catheter. After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client? Standard T