HESI 101/HESI VN Module 1 Exam_ LATEST 2021 ,100% CORRECT

HESI 101/HESI VN Module 1 Exam_ LATEST 2021 Question 1 1 / 1 pts A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson’s theory of psychosocial development, the nurse tells the group that infants have which developmental need? Correct! Need to rely on the fact that their needs will be met Must have needs ignored for short periods to develop a healthy personality Need to tolerate a great deal of frustration and discomfort to develop a healthy personality Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs Rationale: According to Erikson’s theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains the closed-ended word “must.” Eliminate the comparable or alike options and indicate that experiencing frustration is necessary. Review Erikson’s theory of psychosocial development as it relates to the infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate. Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz, at birth, a weight of 13 lb at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling that infants double their weight by 6 months of age will direct you to the correct option. Review the growth rate of an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Correct! Document these measurements in the infant’s health care record. Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant’s head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the infant has a physiological problem. Review the expected growth rate of an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages Correct! "The immune system of an infant is immature, and the infant is at risk for infection." Rationale: Transplacental transfer of maternal antibodies supplements the infant’s weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age, the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed-ended word "all." Recalling that breastfeeding alone does not protect the infant from infection will assist you in eliminating the option that suggests breastfeeding protects the infant. From the remaining options, use the strategy of selecting the umbrella option to answer correctly. Review the physiological concepts related to the maturity of body systems in an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Correct! The infant says "Mama." The infant smiles and coos. The infant babbles single consonants. Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age. Test-Taking Strategy: Use the process of elimination and focus on the subject, the developmental milestone of a 9- month-old. Recalling the language development that occurs during infancy will direct you to the correct option. Remember that an 8- to 9-month-old infant can string vowels and consonants together. Review the developmental milestones related to language development in an infant if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages Rub the infant's gums with baby aspirin that has been dissolved in water. Obtain an over-the-counter (OTC) topical medication for gum- pain relief. Correct! Give the infant cool liquids or a Popsicle and hard foods such as dry toast. Rationale: Although sometimes asymptomatic, teething is often signaled by behavior such as nighttime awakening, daytime restlessness, an increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the health care provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child’s age, can relieve discomfort. Test-Taking Strategy: Focus on the subject, teething and relieving the infant’s discomfort. First recall that it is unnecessary to consult with a dentist. Next, eliminate the comparable or alike options that involve administering medication to the infant. Review the measures that will relieve the discomfort of teething if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Question 7 1 / 1 pts A nurse is teaching the mother of an 11-month-old infant how to clean the infant’s teeth. The nurse tells the mother to take which action? Correct! Use water and a cotton swab and rub the teeth. Use diluted fluoride and rub the teeth with a soft washcloth. Use a small amount of toothpaste and a soft-bristle toothbrush. Dip the infant's pacifier in maple syrup so that the infant will suck. Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant's pacifier in maple syrup is unacceptable because of the risk of tooth decay. Test-Taking Strategy: Use the process of elimination and focus on the subject, cleaning the teeth. Recalling the risk associated with tooth decay will help eliminate the option that identifies the use of maple syrup. To select from the remaining options, noting that the client in the question is an infant will direct you to the correct option. Review the procedure for cleaning teeth in an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Correct! "Egg white should not be given to my infant because of the risk for an allergy." "Meats are really important for iron, and I should start feeding meats to my infant right away." Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant’s intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant’s intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the health care provider’s recommendation, fruits and vegetables may be introduced first. Test-Taking Strategy: Read each option carefully and think about the subject, the principles associated with feeding and nutrition. Recalling that allergy is a concern will direct you to the correct option. Review the principles related to nutrition an infant if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Correct! To secure the infant in the middle of the back seat in a rear-facing infant safety seat To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant That it is acceptable to place the infant in the front seat in a rear- facing infant safety seat as long as the car has passenger-side air bags That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car Rationale: Infants should not be restrained in the front seats of cars. If a passenger-side airbag is deployed, the airbag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that recommend placing the infant in the front seat. To select from the remaining options, keep safety in mind and remember that the infant should never be held and should be placed in an infant safety seat. Review car safety principles for an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? "I need to keep large toys out of the crib." "The drop side needs to be impossible for my infant to release." "Wood surfaces on the crib need to be free of splinters and cracks." Correct! "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body." Rationale: The distance between slats must be no more than 2⅜ inches to prevent entrapment of the infant’s head and body. The mesh in a mesh-sided crib should have openings smaller than ¼ inch. The drop side must be impossible for the infant to release, and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother should avoid placing large toys in the crib because an older infant may use them as steps to climb over the side, possibly resulting in serious injury. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instructions” in the question. These words indicate a negative event query and the need to select the incorrect statement by the mother. Visualizing each of these options and keeping safety in mind will direct you to the correct option. Review crib safety instructions if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 11 1 / 1 pts The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? Initiative versus guilt Trust versus mistrust Industry versus inferiority Correct! Autonomy versus doubt and shame Rationale: According to Erikson, the toddler is struggling with the developmental task of acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers discover that they have wills of their own and that they can control others. Asserting their will and insisting on their own way, however, often lead to conflict with those they love, whereas submissive behavior is rewarded with affection and approval. Toddlers experience conflict because they want to assert their will but do not want to risk losing the approval of loved ones. Trust versus mistrust is the developmental task of the infant. Initiative versus guilt is the developmental task of the preschool- age child. Industry versus inferiority is the developmental task of the school-age child. Test-Taking Strategy: Focus on the data in the question. Note the relationship between the words "a will of his own" and the word "autonomy" in the correct option. Review Erikson's developmental stages if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room. Rationale: The nurse can decrease the stress of hospitalization for the toddler by incorporating the toddler's usual rituals and routines from home into nursing care activities. Keeping hospital routines as similar to those of home as possible and recognizing ritualistic needs gives the toddler some sense of control and security and eases feelings of helplessness and fear. Spending as much time as possible with the toddler and allowing the toddler to play with other children and select the toys he would like to play with may be appropriate interventions, but keeping the hospital routine as similar as possible to the routine at home will best maintain the toddler's sense of control and security and ease feelings of helplessness and fear. Test-Taking Strategy: Note the strategic word "best" in the question. Use the process of elimination and focus on the subject, how to best maintain the toddler's sense of control and security and ease feelings of helplessness and fear. This will assist you in selecting the correct option. Review the psychosocial needs of the toddler with regard to hospitalization if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Developmental Stages Simple board games and puzzles Videos and cutting-and-pasting toys Rationale: Toys for the toddler should meet the child’s needs for activity and inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger paints, and bubbles; push–pull toys; large balls; sand and water play; blocks; painting; coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board games, videos, and cutting-and-pasting toys are more appropriate play activities for the preschooler. Test-Taking Strategy: Focus on the subject, toys appropriate for 2- to 3-year-old children. Remember that all parts of an option need to be correct for the option to be correct. Focusing on the age of the child will direct you to the correct option. Review age-appropriate toys for the toddler if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Developmental Stages Correct! That if she notes the behavior again, she should casually tell her children to dress and to direct them to another activity To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again Rationale: Sex play and masturbation are common among toddlers. Parents should respect the toddler's curiosity as normal without judging the toddler as bad. Parents who discover children involved in sex play may casually tell them to dress and direct them to another play activity, thereby limiting sex play without producing feelings of shame or anxiety. Bringing the children to a child psychologist, separating them at play, and punishing them are all inappropriate. Test-Taking Strategy: Use the process of elimination and focus on the strategic word “toddlers.” Recalling that sex play and masturbation are common among toddlers will direct you to the correct option. Review psychosexual development in the toddler if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages A nurse is assisting with data collection regarding language development in a toddler from a bilingual family. The nurse expects which characteristic in the child’s language development? Correct! Is slower than expected Is developing as expected Is more advanced than expected Will require assistance from a speech therapist Rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. A child from a bilingual family does not require assistance from a speech therapist to ensure language development. Test-Taking Strategy: Use the process of elimination. Note that there are no data in the question to indicate that the child needs assistance from a speech therapist. When selecting from the remaining options, noting the word "bilingual" in the question and recalling the factors that affect language development will direct you to the correct option. Review the factors that affect language development if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Cultural Diversity Rationale: School-age children are able to assume responsibility for their own dental hygiene. Good oral health habits tend to be carried into the adult years, helping prevent cavity formation for a lifetime. Thorough brushing with fluoride toothpaste followed by flossing between the teeth should be done after meals and before bedtime. It is important that parents set up a routine schedule for the child that promotes good daily oral hygiene and gives them responsibility for their own dental care. Test-Taking Strategy: Use the process of elimination. Use the process of elimination. Use the subject, general principles and guidelines related to dental care and select the option that provides the most frequent and thorough dental care. Review principles and guidelines of dental care if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Rationale: Identity formation is the major developmental task of adolescence. Energy is focused within the self, and the adolescent is sometimes described as egocentric or self-absorbed. Frustrated parents often describe teenagers during this phase as self-centered, lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on himself or herself, and determine who he or she is going to be. Erikson describes the conflict of this phase of psychosocial development as identity formation versus role confusion. The assertions that a psychologist is needed and that the behavior is the result of spoiling are incorrect. Restriction of social privileges will cause resentment and rebellion in the adolescent. Test-Taking Strategy: Focus on the adolescent’s behaviors described in the question. Recalling the subject, stages of psychosocial development according to Erikson will direct you to the correct option. Remember that identity formation is a major developmental task of adolescence. Review the psychosocial development of the adolescent if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Obtaining adequate rest and sleep Rationale: Body image is of particular importance to an adolescent. Teenagers tend to be concerned about their weight, complexion, sexual development, and acceptance by their peers. They are not as concerned about obtaining adequate nutrition and tend to eat fast foods and junk foods and may experiment with weight-management techniques such as fasting, diet pills and laxatives, self- induced vomiting, and fad diets. Keeping up with schoolwork may be important to some teenagers, but it is not usually the primary concern. Along with engaging in increasingly independent activities, teenagers tend to stay up late and have difficulty waking in the morning. Obtaining adequate rest and sleep is not teenagers’ primary concern. Test-Taking Strategy: Note the strategic word "primary." Thinking about the psychosocial development of the teenager (adolescent) will direct you to the correct option. Review psychosocial development of the adolescent if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Developmental Stages Correct! Body piercing is generally harmless as long as it is performed under sterile conditions It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV) Rationale: Generally body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some of the complications that may occur are bleeding, infection, keloid formation, and the development of allergies to metal. The area needs to be cleaned at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not associated with body piercing; however, they are a possibility with tattooing. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed-ended word "always." The fact that HIV and hepatitis B are not associated with body piercing will help you eliminate these options. Review the complications associated with body piercing if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety The only way to reduce the risk of transmission of STIs is abstinence. Use of a latex condom is a good method for preventing pregnancy. A spermicide needs to be used along with a condom to prevent transmission of STIs. Rationale: Use of a condom during intercourse can reduce the risk of STI transmission. Abstinence is not the only way to reduce the risk of STI transmission. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs. Test-Taking Strategy: Use the process of elimination and focus on the subject, reduction of the risk of transmission of an STI. Eliminate the option using the closed-ended word “only.” Focusing on the subject will help you select the correct option from the remaining options. Review the methods of reducing the risk of transmission of STIs if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Yong adults are at risk for a serious illness. Young adults are unable to afford health insurance. Young adults are exposed to hazardous substances. Correct! Young adults may ignore physical symptoms and postpone seeking health care. Rationale: Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help the nurse and client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and other chronic diseases. Young adults are not at risk for serious illness. The young adult may or may not be exposed to hazardous substances and may or may not be able to afford health insurance. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, a characteristic of young adults, will direct you to the correct option. Review the characteristics associated with the young adult if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam The young adult is sensitive to criticism. The young adult verbalizes unrealistic fears. The young adult verbalizes disappointment with life. Correct! The young adult verbalizes satisfaction with friendships. Correct! The young adult has a sense of meaning and direction in life. Rationale: Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Signs of emotional health in the young adult include a sense of meaning and direction in life, successful negotiation of transitions, absence of feelings of being cheated or disappointed by life, attainment of several long- term goals, satisfaction with personal growth and development, reciprocated feelings of love for a partner, satisfaction with social interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and no unrealistic fears. Test-Taking Strategy: Focus on the subject, a sign of emotional health. Select the options that use positive words such as “satisfaction” and “meaning and direction.” Review the signs of emotional health in the young adult if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Redefining self-perception and capacity for intimacy Correct Answer Providing guidance during interactions with his children Verbalizing readiness to assume parental responsibilities You Answered Making decisions concerning career, marriage, and parenthood Rationale: According to Erikson’s developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Making decisions concerning career, marriage, and parenthood; redefining self-perception and capacity for intimacy; and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult. Test-Taking Strategy: Use the process of elimination. Eliminate comparable or alike options that relate to marriage and parenting. Also, focusing on the subject, a middle adult, will direct you to the correct option. Review the developmental tasks of the middle adult if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Developmental Stages dysphagia. Which action should the nurse suggest including in the plan of care? Encouraging the client to feed herself Ensuring that most of the diet consists of liquids Correct! Monitoring the client during meals to ensure that food is swallowed Consulting with the physician regarding feeding through an enteral tube Rationale: Clients with dysphagia must be assisted during meals, and the nurse should carefully observe the client to ensure that foods are successfully swallowed instead of being trapped in the mouth. The diet should be nutritionally balanced and consist of both solids and liquids. Aspiration of liquids or solids is possible and may lead to aspiration pneumonia. Thickeners can be added to liquids because thin liquids are most difficult to swallow for clients with dysphagia. Clients with severe dysphagia may require enteral tube feedings, but there is no information in the question to indicate that the dysphagia is severe. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. This will direct you to the correct option. Remember that one risk that exists with dysphagia is aspiration. Review nutritional measures for the older client with dysphagia and dysphagia precautions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety An older client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. On the basis of these reported data, the nurse should take which action? Report the findings to the registered nurse. Correct! Document the findings in the medical record. Ask the registered nurse to obtain a prescription for a nighttime sedative. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours. Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Because the reported data are normal age-related changes, the nurse would document the findings. There is no reason to report the findings to the registered nurse. Sedatives should be avoided. The consumption of caffeinated beverages is likely to increase disruption of sleep patterns. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the age- related changes related to sleep patterns and remembering that those described in the question are normal will direct you to the correct option. Review age- related sleep pattern changes if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages A nurse is assisting with developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan? Encouraging at least one daytime nap Discouraging the use of a nightlight at bedtime Correct! Encouraging bedtime reading or listening to music Discouraging social interaction, particularly at bedtime Rationale: Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading or listening to music. The use of a nightlight will foster an environment that is both helpful and safe. Test-Taking Strategy: Use the process of elimination. Thinking about the safety needs of the older client will assist you in eliminating the option of discouraging the use of a nightlight. To select from the remaining options, focusing on the subject, maintaining an adequate sleep pattern, will direct you to the correct option. Review measures that will maintain an adequate sleep pattern if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Developmental Stages reports concern about sexual dysfunction. Which should be the nurse’s next action? Report the client’s concern to the health care provider. Correct! Ask the client about medications he is taking. Document the client’s concern in the medical record. Tell the client that sexual dysfunction is a normal age-related change. Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. Although the nurse may report the client’s concern and document the concern in his medical record, the next action is to ask the client about the medications he is taking. Test-Taking Strategy: Use the steps of the nursing process to answer the question. This will direct you to the correct option, which is the only option related to data collection. Review the causes of sexual dysfunction in the older client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages It is best to do grocery shopping and other errands late in the day. Clients must stay in the house and ask a neighbor or family member to run their errands. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza. Correct! Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season. Rationale: During peak influenza season, older clients should avoid crowds to decrease the risk of contracting influenza. The nurse should encourage clients to do their shopping and other errands early in the morning, when crowds are smaller, or to have someone else shop for them. Frequent hand hygiene is the best means of avoiding transmission of the flu virus. Drinking eight 8-oz glasses of fluid a day will not reduce the risk of contracting influenza; however, it will prevent dehydration if illness occurs. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed-ended word “must.” Also eliminate the option that uses the words “late in the day.” To select from the remaining options, focusing on the subject of the question, how to decrease the risk of contracting influenza, will direct you to the correct option. Review interventions used to decrease the risk of contracting influenza if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 36 1 / 1 pts A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client’s ability to maintain a patent airway because of which factor involved in the normal aging process? Increased production of surfactant Increased respiratory system compliance Correct! Decreased older client’s ability to clear secretions Decreased number of alveoli and increased function of those remaining Rationale: Respiratory changes related to the normal aging process decrease an older adult’s ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished. Test-Taking Strategy: Use knowledge of the subject, normal age-related changes in the older client. Note the relationship between the words “maintain a patent airway” in the question and “ability to clear secretions” in the correct option. Review the normal age-related changes of the respiratory system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory "The number of sweat glands and blood vessels decreases in the normal aging process." Rationale: The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from ultraviolet rays, paler skin color, and graying hair. Although the skin becomes thinner with the aging process and the number of sweat glands and blood vessels decreases, these changes are unrelated to graying hair. Heredity factors influence when the process of graying begins but do not cause the graying of hair. Test-Taking Strategy: Use knowledge of the subject, and recall the normal process of aging. Note the relationship between the words “turned gray” in the question and “loss of melanin” in the correct option. Review the age-related changes related to the hair if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Correct! "I need to wear additional antiperspirant and deodorant in warm weather." Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and reduced evaporative heat loss because of decreased sweating. The need for antiperspirants and deodorants is decreased. However, older adults are at a greater risk of heatstroke as a result of a compromised cooling mechanism; they should therefore avoid heat exposure over long periods and in areas of high humidity. The older adult should wear a hat with a wide brim and cool, lightweight, light-colored clothing when outdoors. It is also important that the older adult maintain adequate hydration, particularly during the summer and in hot climates. Test-Taking Strategy: Focus on the subject, heatstroke, and note the strategic words “need for further instruction.” These words indicate a negative event query and the need to select the incorrect option. Recall that with aging, bodily changes occur, including a decrease in the number of sweat glands. This will help direct you to the correct option. Review these age-related changes to the skin if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages “I have to hold my newspaper farther and farther away from me when I read.” “If I go from a very bright room to a very dark room, I have some trouble adjusting.” “I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me.” Rationale: Seeing blank spots in the middle of an object is loss of central vision, a symptom of macular degeneration, which would require an immediate discussion with the health care provider. Having to hold close objects farther away is presbyopia, a normal finding with aging. With normal aging, the lens of the eye loses the ability to quickly adjust to changes in lighting. Slight changes in color perception are common with aging. Test-Taking Strategy: Use knowledge of the subject, visual changes with aging, to assist with answering this question. Losing central vision (or any actual loss of vision) is not normal and would warrant an immediate discussion with the health care provider. Review expected changes in vision with aging if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages Difficulty hearing low-pitched tones Correct! Difficulty hearing whispered words in the voice test Improved hearing ability during conversational speech Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and difficulty hearing consonants during conversational speech. Test-Taking Strategy: Use knowledge of the subject, hearing changes in older adults. Eliminate the option containing the words “increased hearing.” Recalling that the hearing loss in presbycusis is bilateral will assist you in eliminating the option containing the word “unilateral.” For you to select from the remaining options, it is necessary to know that the client has difficulty hearing high-pitched tones (not low-pitched tones). Review age-related changes in hearing if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages You Answered Thick skin on the lower legs Bounding dorsalis pedis pulse Correct Answer Loss of hair on the lower legs Rationale: In later adulthood, the dorsalis pedis and posterior tibial pulses may become more difficult to find. They would not be bounding. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick, ridged nails; loss of hair on the lower legs) also occur normally with aging. Test-Taking Strategy: Use knowledge of the subject, changes related to aging in the skin and peripheral vascular systems. Recalling the age-related changes in the skin and cardiovascular system and noting the words “loss of hair” will direct you to the correct option. Review age-related changes in the skin and peripheral vascular systems if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Health Assessment/Physical Exam Ask the registered nurse about referring the client to a neurological specialist. Rationale: Senile tremors are occasionally noted in clients in later adulthood. These benign tremors include intentional tremor of the hands, head-nodding (as if saying “yes”), and tongue protrusion. Because this finding is an age-related occurrence, obtaining a prescription for a muscle relaxant, notifying the registered nurse immediately, and asking about referring the client to a neurological specialist are unnecessary and incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate contact with the registered nurse. Review age-related changes of the neurological system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Health Assessment/Physical Exam Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker's face and lips. The nurse would watch to see that the nursing assistant avoided situations in which there is a glare or shadows on the client's field of vision. The nurse would also remind the assistant to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The assistant should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues. Test-Taking Strategy: Note the strategic word “intervene” in the question. This word indicates that you need to select the option that indicates an incorrect action by the nursing assistant. Visualize each of the options to help direct you to the correct one. Review strategies to improve communication when a client has hearing loss if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Leadership and Management Rationale: African American families are oriented around women. Within the African American family structure, the wife/mother is often charged with the responsibility of protecting the health of family members. The African American woman is expected to assist each family member in maintaining good health and in determining the course of treatment if a family member becomes ill. The nurse must recognize the importance of the African American woman in disseminating information and in assisting the client in making decisions. Although the African American man may be included in the decision- making process, the African American family is often matrifocal, so the nurse ensures that the woman is present. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that identify male members of the family. Review the characteristics of the African American family system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Cultural Diversity That it does not have to be discarded after use and can be used several times before a new one must be obtained Rationale: A female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. The condom, which is prelubricated, is available without a prescription. It cannot be combined with a male condom and should be used just once, then discarded. Like the male condom, the female condom provides protection against STIs. The pregnancy failure rate with typical use is approximately 21%.. Test-Taking Strategy: Use the process of elimination. Noting the strategic word “condom” in the question and recalling that one advantage of using a male condom is the prevention of STIs will direct you to the correct option. Review the advantages and disadvantages of the female barrier device if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Reproductive "The diaphragm can be inserted as long as 6 hours before intercourse." Correct! "I can leave the diaphragm in place as long as I want after intercourse." Rationale: The diaphragm may be inserted as long as 6 hours before intercourse and must remain in place for at least 6 hours after. Because of the risk of toxic shock syndrome, the diaphragm must not remain in place for more than 24 hours. The diaphragm must be filled with spermicidal cream or jelly before insertion, and the spermicide must be reapplied before intercourse is repeated. Test-Taking Strategy: Use the process of elimination and note the strategic words “needs further information.” These words indicate a negative event query and the need to select the incorrect client statement. Recalling that the risk of toxic shock syndrome exists with the use of a diaphragm and noting the words “as long as I want” will direct you to the correct option. Review client instructions for use of a diaphragm if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Reproductive Family planning goals Work and home schedules You Answered Desire to have children in the future Rationale: Personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method. The nurse should educate the client about the various contraceptive methods available so that expressions of preference may be based on understanding. The desire to have children in the future, work and home schedules, and family planning goals may affect the choice of birth control method but are not motivating factors. Test-Taking Strategy: Focus on the subject, the major factor that will provide motivation. This will direct you to the correct option. Review factors to consider when helping a client choose a birth control method if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Reproductive Correct! Sterilization Male condom Rationale: If family planning goals have already been met, sterilization of the male or female partner may be desirable. When sexual activity is limited, use of a spermicide, condom, or diaphragm may be most appropriate. Test-Taking Strategy: Focus on the data in the question, and note that the couple is sexually active and is seeking a method of birth control that is convenient. Eliminate the comparable or alike options that involve the application of a contraceptive method. Review family planning and methods of birth control if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Reproductive Rationale: Oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke. The risk of thromboembolic phenomena is increased in the presence of other risk factors, especially heavy smoking and a history of thrombosis. Additional risk factors include hypertension, cerebrovascular disease, coronary artery disease, and surgery in which postoperative thrombosis might be expected. Dieting, menstrual cramping, and strenuous exercise are not risk factors associated with the use of oral contraceptives. Test-Taking Strategy: Use the process of elimination and note that the question addresses the use of an oral contraceptive. Focusing on the subject, identification of risk factors, will direct you to the correct option. Review the risks associated with oral contraceptives if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Rationale: Combination oral contraceptives contain both estrogen and progestin and are contraindicated during pregnancy and for women who have (or have a history of) the following disorders: thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They are used with caution in women with diabetes mellitus, women who smoke heavily, women with risk factors for cardiovascular disease (hypertension, obesity, hyperlipidemia), and women anticipating elective surgery in which thrombosis might be expected. Test-Taking Strategy: Focus on the subject, a contraindication of a combination oral contraceptive. Recalling that a combination oral contraceptive contains estrogen will direct you to the correct option, breast cancer. Review the contraindications combination oral contraceptive if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology If the oral tablets are not successful, the medication will be administered intravenously. Correct! Multiple births occur in a small percentage of clomiphene- facilitated pregnancies. Rationale: Multiple births (usually twins) occur in a small percentage (8%–10%) of clomiphene-facilitated pregnancies, and the couple should be informed of this. The medication is available in 50-mg tablets for oral use. There is no available intravenous form. Breast engorgement is a common side effect of the medication that reverses after medication withdrawal. When ovulation does occur as a result of use of clomiphene, it is usually within 5 to 10 days after the last dose. The couple is instructed to engage in coitus at least every other day during this time. Test-Taking Strategy: Use knowledge of the subject, use of clomiphene. Note the relationship between the words “treat infertility” in the question and “multiple births” in the correct option. Review use of clomiphene if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Reproductive Correct! Palpable fetal movement Thinning of the cervix Positive result on home urine test for pregnancy Rationale: The positive indicators of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus with sonography. Amenorrhea is a presumptive sign of pregnancy because it is experienced and reported by the woman. Presumptive signs are not reliable indicators of pregnancy, because they may be caused by conditions other than pregnancy. Thinning of the cervix (the Hegar sign) and a positive pregnancy test result are probable indicators of pregnancy. A false-positive pregnancy test result may occur as a result of an error in reading, the presence of protein or blood in the urine, a recent pregnancy, a recent first-trimester abortion, or medications the client is taking. Test-Taking Strategy: Use the process of elimination. Noting the strategic word "confirmed" will assist you in selecting the correct option. Recalling the presumptive, probable, and positive signs of pregnancy will also assist you in answering correctly. Review the positive signs of pregnancy if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Fetoscope Stethoscope Correct! Doppler transducer Pulse oximetry on the client and a fetoscope Rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that involve a fetoscope. To select from the remaining options, note the week of gestation of the client, which will direct you to the correct option. Review the equipment used for auscultating fetal heart sounds if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Wait 15 minutes and then recheck the FHR. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time. Rationale: The normal fetal heart depends on gestational age (usually higher in the first trimester) and is generally in the range of 120 to 160 beats/min. An FHR of 160 beats/min is within the normal range, so documentation is the only action indicated. Test-Taking Strategy: Recalling that the normal FHR is in the range of 120 to 160 beats/min will direct you to the correct option, documenting the findings. Also note that the incorrect options are comparable or alike options, in that they indicate concern over the FHR finding. Review the normal FHR if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother’s abdomen to count the FHR. The nurse simultaneously palpates the mother’s radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? Ask the mother to lie still while both the FHR and the radial pulse rate are counted. Correct! Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse. Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother’s radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother’s abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic souffle (blood flowing through the umbilical cord) and the uterine souffle (blood flowing through the uterine vessels). The funic souffle is synchronized with the FHR; the uterine souffle is synchronized with the mother’s pulse. Test-Taking Strategy: Focus on the data in the question. Noting that the sounds heard through the fetoscope are synchronized with the mother’s radial pulse will help direct you to the correct option. Also note that the incorrect options are comparable or alike options in that they indicate continuing with the counting of the heart rate. Review the procedure for auscultating the FHR if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum A nonreassuring sign An indication of fetal distress An indication of the need to contact the physician Rationale: When determining the FHR, the nurse determines that the findings are reassuring or whether further steps should be taken to clarify data or correct problems. Reassuring signs include an average rate between 120 and 160 beats/min at term; a regular rhythm or a rhythm with slight fluctuations; accelerations from the baseline rate, often occurring with fetal movement; and the absence of decreases from the baseline rate. A nonreassuring sign suggests fetal distress, warranting immediate intervention and indicating the need to contact the physician. Test-Taking Strategy: Use the process of elimination. Note that the incorrect options are comparable or alike options, indicating a problem and the need for immediate intervention. Review reassuring signs during monitoring of the FHR if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Intrapartum That cervical softening is present Correct! That the cervix was seen to be violet Rationale: One probable sign of pregnancy is the Chadwick sign—violet coloration of the cervix, which is normally pink. The color change, which also extends into the vagina and labia, occurs because of increased vascularity of the pelvic organs. Thinning of the cervix is termed the Hegar sign, and softening of the cervix is called the Goodell sign. These are both probable signs of pregnancy. Test-Taking Strategy: Focus on the subject, the Chadwick sign. Recalling that the Chadwick sign is the name given to violet coloration of the cervix, which is normally pink, and that this is a probable sign of pregnancy will direct you to the correct option. Review the presumptive, probable, and positive signs of pregnancy if you had difficulty with this question. Level of Cognitive A