Nokea
A nurse visits a 3-month-old infant of a single mother for a weight check. She finds two older children running around the home, the infant is crying, the mother yelling at the two children and a half-lit cigarette is in an ashtray. The mother tells the nurse the visit needs to be cut short today because she has to pick up her other children from the bus stop. Which of the following would be the most beneficial intervention this nurse can provide during this visit?
- A. Leave and tell the mother to call her to reschedule the appointment.
- B. Weigh the infant and contact the Department of Children and Families.
- C. Weigh the infant and offer community resources to the mother.
- D. Offer to go pick up the other children at the bus stop.
Correct Answer: C
Rationale: Offering community resources helps provide support to the mother and helps prevent potential abuse while maintaining a positive relationship.
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A nurse is caring for a pregnant woman who has a pre-pregnancy body mass index (BMI) of 27. Which of the following instructions should the nurse provide the woman regarding weight gain during pregnancy?
- A. “You should gain 11 to 20 pounds during your pregnancy.”
- B. “You should gain 15 to 25 pounds during your pregnancy.”
- C. “You should gain 25 to 35 pounds during your pregnancy.”
- D. “You should gain 28 to 40 pounds during your pregnancy.”
Correct Answer: B
Rationale: Overweight women (BMI 25-29.9) should gain 15-25 pounds during pregnancy.
The mother of a 13-year-old girl is concerned because her daughter has not started menstruating yet. Which statement would be the most appropriate response from the nurse?
- A. Usually, girls start menstruating when they develop breast buds; an endocrine evaluation might be warranted.
- B. Everyone is different; it will happen when it happens.
- C. Based on when the breast buds first appeared, she should start menstruating around the age of 14.
- D. She will not start menstruating until her breasts are of adult size and contour.
Correct Answer: C
Rationale: Menstruation typically starts about 2 years after breast buds, around age 14.
Which individual is at risk for a dysfunction in elimination pattern?
- A. 46-year-old mother of two
- B. 32-year-old African American man
- C. 72-year-old white woman
- D. 15-year-old girl
Correct Answer: A
Rationale: Various life stages and cultural factors contribute to elimination dysfunction, such as constipation or incontinence.
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: The amount of leisure time is a subjective finding that can influence the activity-exercise pattern and needs to be considered in nursing practice.
A nurse is working with a local daycare center to develop appropriate outdoor play activities for 5-year-old children at the center. Which of the following activities would the nurse most likely recommend?
- A. Having the children bring their bikes to the center so they can go for bike rides in the neighborhood
- B. Playing hopscotch on the sidewalk in front of the daycare center
- C. Taking the children swimming at the neighborhood pool
- D. Playing on the outdoor preschool equipment while being supervised by daycare personnel
Correct Answer: D
Rationale: Outdoor play should involve activities that are safe and supervised. Preschoolers are not ready for unsupervised outdoor bike rides or swimming.