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A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?
- A. Stethoscope
- B. Doppler transducer
- C. Fetoscope
- D. Pulse oximetry on the client and a fetoscope
Correct Answer: B
Rationale: To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. 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, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.
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A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?
- A. Thin, ridged toenails
- B. Thick skin on the lower legs
- C. Loss of hair on the lower legs
- D. Bounding dorsalis pedis pulse
Correct Answer: C
Rationale: In later adulthood, age-related findings include trophic changes associated with arterial insufficiency, such as thin, shiny skin; thin, ridged toenails; and loss of hair on the lower legs. These changes occur normally with aging. Thick skin on the lower legs would not be an expected age-related finding as it typically indicates chronic venous insufficiency. A bounding dorsalis pedis pulse is not typical in later adulthood and may indicate arterial insufficiency, which is not an age-related finding.
According to Erikson, which developmental task is a toddler confronting when they develop 'a will of his own' and 'acts as if he can control others'?
- A. Trust versus mistrust
- B. Autonomy versus doubt and shame
- C. Initiative versus guilt
- D. Industry versus inferiority
Correct Answer: B
Rationale: According to Erikson, the correct developmental task for a toddler who has developed 'a will of his own' and 'acts as if he can control others' is Autonomy versus doubt and shame. Toddlers at this stage are asserting their wills and realizing they can control others, which is part of developing autonomy. However, they may also experience doubt and shame if their assertiveness is met with disapproval. Trust versus mistrust is the developmental task of the infant, where the main focus is on developing trust in the caregiver. Initiative versus guilt is the developmental task of the preschool-age child, emphasizing the balance between taking initiative and feeling guilty. Industry versus inferiority is the developmental task of the school-age child, focusing on competence and self-esteem.
A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the healthcare provider expect to administer in addition to the scheduled vaccines?
- A. pneumococcal vaccine
- B. hepatitis A vaccine
- C. Lyme disease vaccine
- D. typhoid vaccine
Correct Answer: A
Rationale: The correct answer is the pneumococcal vaccine. Children with HIV are at increased risk of pneumococcal infections, so the pneumococcal vaccine is recommended as a supplemental vaccine for them. The hepatitis A vaccine is not routinely given to HIV-positive children unless they have other risk factors for hepatitis A. Lyme disease vaccine is for individuals at risk for Lyme disease, not routinely recommended for a 2-year-old. Typhoid vaccine is typically given to individuals traveling to endemic areas or working in settings with potential exposure to Salmonella typhi, not a routine vaccine for a 2-year-old with HIV.
A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct Answer: B
Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.
Client self-determination is the primary focus of:
- A. malpractice insurance.
- B. nursing's advocacy for clients.
- C. confidentiality.
- D. health care.
Correct Answer: B
Rationale: Client self-determination is the primary focus of nursing's advocacy for clients. Nurses advocate for their clients' right to autonomy and self-determination, ensuring that the clients' preferences and choices are respected. Confidentiality, on the other hand, involves maintaining the privacy of the client and their information. Health care is a broad term encompassing various aspects of medical services. Malpractice insurance is a type of insurance that provides coverage for professionals in case of negligence or malpractice, not directly related to client self-determination.