Regarding maternal and infant mortality and morbidity, a concern is that:
- A. a segment of the population is not receiving prenatal care.
- B. families may not prioritize quality health care.
- C. there might be an increase in the shortage of personnel in the maternity field.
- D. maternal-child health workers may lack adequate preparation.
Correct Answer: A
Rationale: The correct answer is that a segment of the population is not receiving prenatal care. This is a significant concern as lack of access to prenatal care can lead to adverse outcomes for both the mother and the infant. Choice B is incorrect as it generalizes families as unconcerned, which may not be the case for all families. Choice C is also incorrect as there is no evidence or indication in the prompt to suggest an increase in the shortage of personnel. Choice D is not directly related to the concern mentioned in the prompt, which specifically focuses on the lack of prenatal care.
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During the health screening of an adolescent, which finding by the nurse requires further teaching?
- A. The client started her first menses 2 years ago.
- B. The client states she is currently taking birth control pills.
- C. The client states she recently lost 5 pounds.
- D. The client states she is experiencing growing pains.
Correct Answer: B
Rationale: The correct answer is 'The client states she is currently taking birth control pills.' This finding requires further teaching because being on birth control pills does not protect against sexually transmitted diseases (STDs), and the adolescent should be educated on the importance of using barrier methods (e.g., condoms) for STD prevention. Choices A, C, and D are not concerning. Choice A is a normal developmental milestone in adolescence. Choice C could indicate a positive lifestyle change, and choice D is a common complaint during this stage of development.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.
What is the primary focus of a case manager?
- A. Addressing nursing care needs at discharge.
- B. Managing the comprehensive care needs of the client for continuity of care.
- C. Providing client education needs upon discharge.
- D. Securing financial resources for needed care.
Correct Answer: B
Rationale: The correct answer is 'Managing the comprehensive care needs of the client for continuity of care.' Case managers oversee all aspects of a client's care to ensure continuity throughout their healthcare journey. Choice A is incorrect as it focuses only on nursing care needs at discharge, which is just a part of the overall care needed. Choice C narrows down the focus to client education needs, excluding other essential care components. Choice D solely considers financial resources, neglecting the broader scope of care needs that a case manager is accountable for.
A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?
- A. Smiling
- B. Clenching the teeth
- C. Shrugging the shoulders against the nurse's resistance
- D. Identifying by taste a substance placed on the back of the tongue
Correct Answer: C
Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.
A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?
- A. Provide her with copies of the approved dietary guidelines from the American Diabetes Association and the American Heart Association.
- B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
- C. Provide a high-protein diet plan for the client.
- D. Provide the client with information related to risk factors for heart disease and diabetes.
Correct Answer: B
Rationale: The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.
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