Nokea
A home health nurse is admitting a 54-year-old man for services following a coronary artery bypass graft (CABG). What is the purpose of this nursing action?
- A. Allows for inclusion of family members in decision-making
- B. Allows for health promotion and disease prevention appraisal
- C. Allows for development of patient-centered care
- D. Allows for data collection necessary for comparison to Healthy People 2020
Correct Answer: B
Rationale: Family assessments enable health promotion, disease prevention, and include family in decision-making.
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Which of the following women should be screened for breast cancer?
- A. A 35-year-old woman with three children and no family history of breast cancer
- B. A 59-year-old woman with no children who still gets her period every month
- C. A 25-year-old woman with one child whom she gave birth to when she was a teenager
- D. A 17-year-old woman with one child who started menstruating at the age of 13
Correct Answer: B
Rationale: Breast cancer screening is recommended for women over 40, as the incidence increases with age.
When assessing a client’s activity-exercise pattern, which subjective finding has implications for nursing practice?
- A. A person’s decreased muscle tone
- B. A person’s amount of leisure time
- C. A person’s decreased range of motion
- D. A person’s use of a cane
Correct Answer: B
Rationale: Leisure time is a subjective finding influencing the assessment of activity and exercise patterns.
A mother tells the nurse that ever since she started toileting training, the toddler has been touching his genitals. Which of the following statements is the most appropriate response by the nurse?
- A. “This is a sign that he is not ready to toilet train yet.”
- B. “This behavior is developmentally normal.”
- C. “Tell him to stop touching himself.”
- D. “Don’t worry about it.”
Correct Answer: B
Rationale: Curiosity about genitals is a normal developmental phase during toilet training.
Which of the following statements can be identified as a method for clarifying a message?
- A. “I get very upset when you talk to me in that tone.”
- B. “You make me very angry when you drink alcohol.”
- C. “I can make you happy. I know I can.”
- D. “What I want from you is to be left alone!”
Correct Answer: A
Rationale: Using "I" statements helps clarify and qualify the message, making it more direct and less accusatory.
A mother is concerned because her 13-year-old daughter comes home happy one day and sad the next. Which of the following is the best initial response from the nurse?
- A. The changes during adolescence can be stressful as they struggle to come to terms with who they are. What other types of behaviors has she been displaying?
- B. Changes in affect can be a warning sign for suicide. Has she had any increase in risk-taking behaviors or physical violence?
- C. Is there any history of psychological disorders in your family?
- D. Withdrawal can be a sign of substance abuse. Has she given you any indication she might be using illicit drugs?
Correct Answer: A
Rationale: Mood swings are typical during adolescence, but further investigation is needed if other concerning behaviors are present.