Results for Lesson 3: Health Promotion and Maintenance

Questions are numbered by the order in which they appeared in the test.
Represents the correct answer.
Question 1
While the nurse is administering medications to a client, Answers Correct C
the client states "I do not want to take that medicine today." Student's C
Which of the following responses by the nurse would be
best?
"That's OK, its all right to skip your medication now
A)
and then."
B) "I will have to call your doctor and report this."
"Is there a reason why you don't want to take your
C)
medicine?"
"Do you understand the consequences of refusing
D)
your prescribed treatment?"
Review Information: The correct answer is C: "Is there a reason why you don''t want
to take your medicine?"
When a new problem is identified, it is important for the nurse to collect accurate
assessment data. This is crucial to ensure that client needs are adequately identified in
order to select the best nursing care approaches. The nurse should try to discover the
reason for the refusal which may be that the client has developed untoward side
effects.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 2
A 64 year-old client scheduled for surgery with a general Answers Correct D
anesthetic refuses to remove a set of dentures prior to Student's B
leaving the unit for the operating room. What would be the
most appropriate intervention by the nurse?
Explain to the client that the dentures must come out
A)
as they may get lost or broken in the operating room
Ask the client if there are second thoughts about
B)
having the procedure
Notify the anesthesia department and the surgeon of
C)
the client's refusal
Ask the client if the preference would be to remove
D)
the dentures in the operating room receiving area
Review Information: The correct answer is D: Ask the client if the preference would
be to remove the dentures in the operating room receiving area
Clients anticipating surgery may experience a variety of fears. This choice allows the
client control over the situation and fosters the client''s sense of self-esteem and self-
concept.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Question 3
The nurse is teaching the parents of a 3 month-old infant Answers Correct A
about nutrition. What is the main source of fluids for an Student's A
infant until about 12 months of age?
A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
D) Fluoridated tap water
Review Information: The correct answer is A: Formula or breast milk
Formula or breast milk are the perfect food and source of nutrients and liquids up to 1
year of age.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 4
The nurse is assessing a 4 month-old infant. Which motor Answers Correct A
skill would the nurse anticipate finding? Student's A
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye"
Review Information: The correct answer is A: Hold a rattle
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6
months.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 5
A client is admitted to the hospital with a history of Answers Correct D
confusion. The client has difficulty remembering recent Student's D
events and becomes disoriented when away from home.
Which statement would provide the best reality orientation
for this client?
A) "Good morning. Do you remember where you are?"
"Hello. My name is Elaine Jones and I am your nurse
B)
for today."
"How are you today? Remember, you're in the
C)
hospital."
"Good morning. You’re in the hospital. I am your
D)
nurse Elaine Jones."
Review Information: The correct answer is D: "Good morning. You’re in the
hospital. I am your nurse Elaine Jones."
As cognitive ability declines, the nurse provides a calm, predictable environment for
the client. This response establishes time, location and the caregiver’s name.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition).
Prentice Hall: Upper Saddle River, New Jersey.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 6
The family of a 6 year-old with a fractured femur asks the Answers Correct B
nurse if the child's height will be affected by the injury. Student's B
Which statement is true concerning long bone fractures in
children?
Growth problems will occur if the fracture involves
A)
the periosteum
Epiphyseal fractures often interrupt a child's normal
B)
growth pattern
Children usually heal very quickly, so growth
C)
problems are rare
Adequate blood supply to the bone prevents growth
D)
delay after fractures
Review Information: The correct answer is B: Epiphyseal fractures often interrupt a
child''s normal growth pattern
The epiphyseal plate in children is where active bone growth occurs. Damage to this
area may cause growth arrest in either longitudinal growth of the limb or in
progressive deformity if the plate is involved. An epiphyseal fracture is serious
because it can interrupt and alter growth.

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease
processes. (6th edition). Mosby: St. Louis, Missouri.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 7
The nurse has been teaching adult clients about cardiac Answers Correct D
risks when they visit the hypertension clinic. Which Student's D
evaluation data would best measure learning?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes
Review Information: The correct answer is D: Reported behavioral changes
If the client alters behaviors such as smoking, drinking alcohol, and stress
management, these suggest that learning has occurred. Additionally, physical
assessments and lab data may confirm risk reduction.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.
(5th edition). St. Louis, Missouri: Mosby.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Question 8
When screening children for scoliosis, at what time of Answers Correct D
development would the nurse expect early signs to appear? Student's C
A) Prenatally on ultrasound
B) In early infancy
C) When the child begins to bear weight
D) During the preadolescent growth spurt
Review Information: The correct answer is D: During the preadolescent growth spurt
Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable
at the beginning of the preadolescent growth spurt. It is more common in females than
in males.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 9
When teaching effective stress management techniques to Answers Correct B
a client 1 hour before surgery, which of the following Student's B
should the nurse recommend?
A) Biofeedback
B) Deep breathing
C) Distraction
D) Imagery
Review Information: The correct answer is B: Deep breathing
Deep breathing is a reliable and valid method for reducing stress, and can be taught
and reinforced in a short period pre-operatively.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Question 10
When teaching a 10 year-old child about their impending Answers Correct D
heart surgery, which form of explanation meets the Student's A
developmental needs of this age child?
A) Provide a verbal explanation just prior to the surgery
Provide the child with a booklet to read about the
B)
surgery
Introduce the child to another child who had heart
C)
surgery 3 days ago
D) Explain the surgery using a model of the heart
Review Information: The correct answer is D: Explain the surgery using a model of
the heart
According to Piaget, the school age child is in the concrete operations stage of
cognitive development. Using something concrete, like a model will help the child
understand the explanation of the heart surgery.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Question 11
The nurse is assessing a client who states her last menstrual Answers Correct D
period was March 16, and she has missed one period. She Student's D
reports episodes of nausea and vomiting. Pregnancy is
confirmed by a urine test. What will the nurse calculate as
the estimated date of delivery (EDD)?
A) April 8
B) January 15
C) February 11
D) December 23
Review Information: The correct answer is D: December 23
Naegele''s rule states: Add 7 days and subtract 3 months from the first day of the last
regular menstrual period to calculate the estimated date of delivery.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness.
Upper Saddle River, New Jersey: Prentice Hall.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 12
When observing 4 year-old children playing in the hospital Answers Correct D
playroom, what activity would the nurse expect to see the Student's D
children participating in?
A) Competitive board games with older children
Playing with their own toys along side with other
B)
children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers
Review Information: The correct answer is D: Playing cooperatively with other
preschoolers
Cooperative play is typical of the late preschool period.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition).
Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.

Question 13
A client states, "People think I’m no good, you know what Answers Correct C
I mean?" Which of these responses would be most Student's C
therapeutic?
"Well people often take their own feelings of
A)
inadequacy out on others."
"I think you’re good. So you see, there’s one person
B)
who likes you."
"I’m not sure what you mean. Tell me a bit more
C)
about that."
"Let's discuss this to see the reasons you create this
D)
impression on people."
Review Information: The correct answer is C: "I’m not sure what you mean. Tell me
a bit more about that."
This therapeutic communication technique elicits more information, especially when
delivered in an open, non-judgmental fashion.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Question 14
A client being treated for hypertension returns to the Answers Correct A
community clinic for follow up. The client says, "I know Student's A
these pills are important, but I just can't take these water
pills anymore. I drive a truck for a living, and I can't be
stopping every 20 minutes to go to the bathroom." Which
of these is the best nursing diagnosis?
A) Noncompliance related to medication side effects
Knowledge deficit related to misunderstanding of
B)
disease state
C) Defensive coping related to chronic illness
D) Altered health maintenance related to occupation
Review Information: The correct answer is A: Noncompliance related to medication
side effects
The client kept his appointment, and stated he knew the pills were important. He is
unable to comply with the regimen due to side effects, not because of a lack of
knowledge about the disease process.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th
edition). Philadelphia: Saunders.

Question 15
A partner is concerned because the client frequently Answers Correct A
daydreams about moving to Arizona to get away from the Student's A
pollution and crowding in southern California. The nurse
explains that
such fantasies can gratify unconscious wishes or
A)
prepare for anticipated future events
detaching or dissociating in this way postpones
B)
painful feelings
converting or transferring a mental conflict to a
C) physical symptom can lead to conflict within the
partnership
isolating the feelings in this way reduces conflict
D)
within the client and with others
Review Information: The correct answer is A: such fantasies can gratify unconscious
wishes or prepare for anticipated future events
Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify
unconscious wishes.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ:
Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical

Approach (4th ed.). Philadelphia: Saunders.

Question 16
The nurse is planning care for an 18 month-old child. Answers Correct B
Which action should be included in the child's care? Student's C
A) Hold and cuddle the child frequently
B) Encourage the child to feed himself finger food
Allow the child to walk independently on the nursing
C)
unit
D) Engage the child in games with other children
Review Information: The correct answer is B: Encourage the child to feed himself
finger food
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt.
The nurse should encourage increasingly independent activities of daily living that
allow the toddler to assert his budding sense of control.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.
(5th edition). St. Louis, Missouri: Mosby.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition).
Philadelphia, PA: Lippincott Williams & Wilkins.

Question 17
An appropriate treatment goal for a client with anxiety Answers Correct C
would be to Student's A
A) ventilate anxious feelings to the nurse
B) establish contact with reality
C) learn self-help techniques
D) become desensitized to past trauma
Review Information: The correct answer is C: learn self-help techniques
Exploring alternative coping mechanisms will decrease present anxiety to a
manageable level. Assisting the client to learn self-help techniques will assist in
learning to cope with anxiety.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.

Question 18
While caring for a client, the nurse notes a pulsating mass Answers Correct B
in the client's periumbilical area. Which of the following Student's B
assessments is appropriate for the nurse to perform?
A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass
Review Information: The correct answer is B: Auscultate the mass
Auscultation of the abdomen and finding a bruit will confirm the presence of an
abdominal aneurysm and will form the basis of information given to the provider. The
mass should not be palpated because of the risk of rupture.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition).
Philadelphia, PA: Lippincott Williams & Wilkins.
Question 19
A client with congestive heart failure is newly admitted to Answers Correct C
home health care. The nurse discovers that the client has Student's C
not been following the prescribed diet. What would be the
most appropriate nursing action?
Discharge the client from home health care because
A)
of noncompliance
Notify the provider of the client's failure to follow
B)
prescribed diet
Discuss diet with the client to learn the reasons for
C)
not following the diet
D) Make a referral to Meals-on-Wheels
Review Information: The correct answer is C: Discuss diet with the client to learn the
reasons for not following the diet
When new problems are identified, it is important for the nurse to collect accurate
assessment data. Before reporting findings to the provider, it is best to have a complete
understanding of the client''s behavior and feelings as a basis for future teaching and
intervention.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.
(5th edition). St. Louis, Missouri: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 20
The parents of a child who has suddenly been hospitalized Answers Correct D
for an acute illness state that they should have taken the Student's D
child to the pediatrician earlier. Which approach by the
nurse is best when dealing with the parents' comments?
A) Focus on the child's needs and recovery
B) Explain the cause of the child's illness
C) Acknowledge that early care would have been better
D) Accept their feelings without judgment
Review Information: The correct answer is D: Accept their feelings without
judgment
Parents often blame themselves for their child''s illness. Feeling helpless and angry is
normal and these feelings must be accepted.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.