Health Promotion Assessment

The bones are not fractured, but the ankle is severely sprained. When should the nurse advise the client to rewrap the elastic bandage following discharge?

After medical stabilization, the client is transferred to a rehabilitation unit. When the nursing team discusses the client’s plan of care, what has the highest priority?

The nurse re-evaluates the student’s eye 48 hours later. The student still reports eye discomfort, and redness is noted across the sclera. When updating the plan of care, to which professional is it best to refer the student for follow-up care?

A nurse volunteers to do blood pressure screenings at a local community hospital’s annual health fair. What nursing modification is most appropriate when taking the blood pressure of a client who weighs 250 lb (113.4 kg)?

While helping a client onto the examination table, the nurse notes that the client has several large protruding leg veins. What risk factor revealed in the client’s health history is most closely related to the development of varicose veins?

During a visit to the health care provider’s office, a client angrily states to the nurse that the health care provider would not prescribe an antibiotic for a head cold. The client states, “I have felt awful for 3 days.” When de-escalating the situation, what explanation to the client by the nurse regarding the use of antibiotics is best?

A 75-year-old client with metastatic cancer of the esophagus is undergoing palliative treatment that includes total parenteral nutrition (TPN) administered through a central subclavian catheter. What nursing assessment is essential for evaluating the client’s response to the total parenteral nutrition (TPN)?

A 33-year-old develops jaundice and presents to the public health department. Testing reveals that the cause of the client’s jaundice is hepatitis B. The nurse gathers information regarding the client’s social history. What information from the client’s history indicates a predisposition for acquiring hepatitis B? Select all that apply.

During bladder retraining, the client tells the nurse about intending to restrict fluid intake to remain dry for longer periods of time. What response by the nurse is best?

A 30-year-old woman has an appointment for a routine pelvic examination. The client asks the office nurse when to begin undergoing routine mammography. The client states that she is asymptomatic and has no first-degree relatives who have breast cancer. The nurse advises that general consensus is a baseline mammogram is acceptable to begin:

A 30-year-old woman and her spouse present to an infertility clinic. They have no children and have had several appointments with the health care provider regarding their infertility problems. The client is instructed on use of an ovulation predictor test to maximize efforts of trying to conceive. If the client identifies today as a time when an ovum is available for fertilization, when should the nurse instruct that it is best for the male to attempt to fertilize?

A 25-year-old primigravid client in the last trimester of pregnancy calls the health care provider’s office and tells the nurse, “I think I’m in labor.” What findings warrant instructing the client to notify the health care provider and report to the hospital’s labor and delivery unit immediately? Select all that apply.

The nurse in a well-baby clinic assesses the growth and development of healthy infants and toddlers and uses that information as a basis for teaching. For what age-appropriate developmental milestone of a 3-month-old infant will the nurse develop parental teaching?

The child is placed on bed rest and started on penicillin V and aspirin. What diversional activity suggested by the nurse is most appropriate for the child during the acute phase of rheumatic fever?

A client who golfs at least three times a week has been experiencing wrist pain aggravated by movement. The condition is diagnosed as tenosynovitis; avoiding repetitive wrist motion is recommended. What statement to the nurse provides the best evidence that the client understands the therapeutic plan?

An older adult diagnosed with Parkinson disease is admitted to a nursing home for basic nursing care. What goal is most realistic when the nurse cares for the client with Parkinson disease?

The nurse uses a Snellen chart to assess a client’s visual acuity. The Snellen chart is placed in the hall.  In preparing for an accurate screening, which factor is most important?

The client undergoes a bilateral adrenalectomy to correct Cushing’s syndrome. What statement to the nurse provides the best evidence that the client who has undergone a bilateral adrenalectomy understands the postoperative course?

A nurse volunteers to do blood pressure screenings at a local community hospital’s annual health fair. When the nurse teaches a client’s spouse how to take a blood pressure measurement, when is the correct time to note the diastolic blood pressure reading?

While helping a client onto the examination table, the nurse notes that the client has several large protruding leg veins. The nurse provides discharge instructions to the client with varicose veins. For what planned activity, when stated by the client, would the nurse need to provide additional teaching?

The client returns to the health care provider’s office and the nurse updates the medical record. When teaching the client about nasal decongestant sprays, what adverse effect is most important to stress?

The client with chronic obstructive pulmonary disease (COPD) receives I.V. fluid containing aminophylline. The nurse performs postural drainage on the client. What nursing intervention is most beneficial to loosen secretions?

A 33-year-old develops jaundice and presents to the public health department. Testing reveals that the cause of the client’s jaundice is hepatitis B. The nurse gathers information regarding the client’s social history. What measure is most appropriate if a nurse who has not received a series of vaccinations for hepatitis B experiences a needlestick injury while caring for an infected client?

To relieve the client’s urinary symptoms, phenazopyridine is prescribed. The nurse prepares information for client discussion. What nursing recommendation(s) is most effective in reducing the potential for bacterial growth in a female client’s bladder? Select all that apply.

Despite the fact that breast self-examination (BSE) does not show a clear benefit, the client intends to continue the practice to develop breast self-awareness. The client states that she examines her breasts in the shower and while lying down. The nurse recommends that the client should also inspect her breasts from what position?

The nurse interacts with the parents of a child born with myelomeningocele. To ensure optimum mental health of an infant born with a congenital defect, what psychosocial need is most important for the nurse to stress regarding parenting the infant?

An obese 25-year-old with a history of dextroamphetamine misuse attends the eating disorder group meeting. What finding in the client’s nursing history strongly suggests the client has not achieved the characteristic developmental level expected at this age in the life cycle?

Despite the fact that breast self-examination (BSE) does not show a clear benefit, the client intends to continue the practice to develop breast self-awareness. The client demonstrates the breast palpation technique used for breast self-examination. The nurse confirms correct technique as the client palpates the breast using the:

A 30-year-old woman and her spouse present to an infertility clinic. They have no children and have had several appointments with the health care provider regarding their infertility problems. The client’s husband states that he has been diagnosed with a low sperm count. To improve sperm production, the nurse should instruct the client’s husband to avoid which activity(ies)? Select all that apply.

The client arrives at the hospital and is admitted to the labor, delivery, recovery, and postpartum (LDRP) unit. The nurse obtains the client’s health and pregnancy history. When obtaining a client’s admission history, which data are most pertinent? Select all that apply.

The nurse in a well-baby clinic assesses the growth and development of healthy infants and toddlers and uses that information as a basis for teaching. After a routine immunization for measles, mumps, and rubella (MMR), the nurse instructs on side effects. What should the nurse emphasize as a priority for the parents to report?

The parents question how their child got rheumatic fever and ask if the child can get it again. The nurse teaches the parents the disease process and potential consequences in the future. What statement by the parents best indicates that the nurse’s teaching has been effective?

The client needs a sling to support the injured shoulder, but a commercially made sling is not available. When the nurse teaches a family member how to apply a triangular sling made from muslin, which statement indicates the need for further teaching?

During a physical assessment, the nurse notes that the client experiences weakness and numbness in various parts of the body. When the client’s discharge is anticipated, the nurse provides suggestions to the family about vacation areas to avoid. What areas should the nurse stress avoiding?

The nurse uses a Snellen chart to assess a client’s visual acuity. The Snellen chart is placed in the hall. The visual acuity is documented as 20/40 (6/12) in the client’s medical record. How is this compared to the person who sees 20/20 (6/6)?

A nurse participates in a community-wide screening to identify adults who may have undiagnosed diabetes mellitus. When the nurse instructs on various tests to diagnose diabetes mellitus, what explanation of a glucose tolerance test is most accurate?

A client has been recording blood pressure readings for the health care provider to review. The client asks the nurse why it is important to control hypertension and if there is anything that can be done. The nurse instructs on prevention techniques aimed at which long-term negative effect?

A client who is severely anemic will receive 2 units of packed blood cells. The client verbalizes concern about becoming human immunodeficiency syndrome (HIV) positive from receiving transfusions of publicly donated blood. What is the best nursing response?

The client returns to the health care provider’s office and the nurse updates the medical record. The nurse is teaching the client how to self-administer nose drops. When evaluating the client’s technique, what method would the nurse identify as correct?

On examination of the adolescent parent’s infant, no signs of illness are identified. What information is most helpful for the nurse to obtain next?

A nurse is assigned to care for a 35-year-old client who sustained a severe head injury and brain damage in a motor vehicle accident. What nursing action is most appropriate when performing a mental status assessment on the client who sustained a head injury?

To relieve the client’s urinary symptoms, phenazopyridine is prescribed. The nurse prepares information for client discussion. When teaching a client with an overactive bladder about urinary tract irritants, what common beverage(s) does the nurse correctly identify as item(s) that cause urinary symptoms? Select all that apply.

Despite the fact that breast self-examination (BSE) does not show a clear benefit, the client intends to continue the practice to develop breast self-awareness. What statement demonstrates to the nurse the client’s understanding of when breast self-examination should be performed?

The client tells the nurse that despite desperately wanting to have a baby, the client is concerned about a vaginal birth because of small hips. What response by the nurse is most appropriate when addressing the client’s concerns?

The client informs the nurse about a previous admission to the unit 3 days ago with “false labor.” What statement made by the client indicates a characteristic of Braxton Hicks contractions?

The nurse provides instructions about the proper administration of oral medications in liquid form to the parents of an infant. What parental statement best confirms an understanding of instruction?

The child has completely recovered from ketoacidosis and is receiving regular insulin and isophane insulin suspension subcutaneously. The blood glucose levels have stabilized, and the health care provider requests starting client education on managing diabetes at home. What statement by the child indicates to the nurse that education on diabetes management has been effective?

The client’s fractured hip is stabilized with an open reduction and internal fixation (ORIF) using a Smith-Peterson nail. Postoperatively, the nurse teaches the client how to perform isometric quadriceps setting exercises. What instruction is accurate?

The client’s care plan indicates to use the Crede maneuver to promote urination.  What nursing observation provides evidence that the client is performing the Crede maneuver correctly?

A low-sodium diet is recommended for a client with hypertension. The best evidence that the client understands the nurse’s instructions regarding dietary restrictions is if the client says he or she should avoid which item?