Nokea
Nursing priority for incontinence: What should be the focus?
- A. "Risk for social isolation."
- B. "Risk for impaired skin integrity."
- C. "Risk for inadequate fluid intake."
- D. "Risk for impaired coping."
Correct Answer: B
Rationale: Impaired skin integrity is a primary concern due to the risk of skin breakdown from incontinence.
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During the first prenatal visit, the pregnant woman informs the nurse that she cannot wait to start wearing maternity clothes. This finding is based on an assessment of which functional health pattern?
- A. Cognitive-perceptual pattern
- B. Self-perception–self-concept pattern
- C. Health-perception–health-management pattern
- D. Values-beliefs pattern
Correct Answer: B
Rationale: Excitement about wearing maternity clothes suggests the woman has accepted her changing body image, part of the self-perception–self-concept pattern.
During a home visit, the nurse finds a 9-month-old in a playpen with a couple of toys. Which of the following instructions would be most appropriate for the nurse to provide to the parent to encourage growth and development of the child?
- A. Encourage the addition of a few more toys to the playpen.
- B. Suggest keeping the infant in the playpen as much as possible to promote safe play.
- C. Encourage providing the infant with supervised time outside of the playpen.
- D. Suggest removing all toys from the playpen.
Correct Answer: C
Rationale: At 9 months, the infant should be encouraged to explore outside the playpen to aid in physical development and motor skills.
Which individuals have a higher than average risk of homicide?
- A. 33-year-old woman who served 5 years in prison
- B. 20-year-old homeless man
- C. 28-year-old man with a history of bipolar disorder
- D. 24-year-old woman with a female partner
Correct Answer: B
Rationale: Homelessness and a history of violence place individuals at a significantly higher risk of homicide.
A nurse is encouraging parents to immunize their infants. Which of the following strategies would be the best way for the nurse to facilitate this?
- A. Send a reminder for immunizations to the parents.
- B. Talk to the parents about immunizations during office visits.
- C. Track clients who have not been immunized.
- D. Memorize the CDC immunization schedule.
Correct Answer: B
Rationale: Direct communication with parents during office visits is most effective in encouraging immunizations.
An overweight woman is in the preparation stage of change. Which of the following interventions would be the most appropriate for the nurse to implement?
- A. Inform her of the health risks associated with being overweight
- B. Prepare her for the setbacks
- C. Develop a low-calorie/low-fat diet with her so she can follow it at home
- D. Praise her for her recent successes
Correct Answer: C
Rationale: In the preparation stage, the woman is ready to make changes, so providing tools like a low-calorie diet plan helps facilitate action.