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The nurse is working at an osteoporosis screening clinic and is interviewing and performing health assessments on women. Which clients are at greatest risk for developing osteoporosis? Select all that apply.
- A. An Asian woman
- B. A large-boned, dark-skinned woman
- C. A client who started menopause early
- D. A client with a family history of the disease
- E. A client who has a physically active lifestyle
- F. A client with an inadequate intake of calcium and vitamin D
Correct Answer: A,C,D,F
Rationale: Risk factors for osteoporosis include being of Asian or Caucasian descent, early menopause, a family history of osteoporosis, and inadequate intake of calcium and vitamin D. Large-boned, dark-skinned women (e.g., those of African descent) have a lower risk due to higher bone density. A physically active lifestyle is protective against osteoporosis, reducing the risk.
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The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.
A mother infected with hepatitis B asks the nurse about the possibility of breastfeeding her neonate. Which response by the nurse would be most appropriate?
- A. Yes, breastfeeding is an acceptable option.
- B. No, you should not breastfeed your baby.
- C. Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine.
- D. Bottled formula is just as nutritious for your baby.
Correct Answer: C
Rationale: Breastfeeding is safe for hepatitis B-positive mothers if the neonate is vaccinated and receives immunoglobulin, reducing transmission risk.
Which problems should the nurse counsel adoptive parents about encountering? Select all that apply.
- A. Setting unrealistically high standard for themselves
- B. Lacking basic knowledge about the child's biological health history
- C. Having difficulty assimilating if the child is adopted from another country
- D. Having difficulty deciding when and how to tell the child about being adopted
- E. Feeling the need for more assistance and support in child-rearing than biological parents do
- F. Dealing with feelings of loss and grief in the child regarding family social history and traditions
Correct Answer: A,B,C,D,F
Rationale: Adoptive parents may add pressure to themselves by setting unrealistically high standards for themselves. Additional problems adoptive families may face include possible lack of knowledge about the child's biological health history, difficulty assimilating if the child is adopted from another country, difficulty deciding when and how to tell the child about being adopted, and dealing with social and traditional issues of the biological family. Otherwise, most problems faced by adoptive parents are no different from those encountered by natural parents. All parents want to be good parents. Both adoptive parents and biological parents need information, support, and guidance to prepare them to care for their child.
The nurse is discussing developmental stages with the mother of a six-month-old infant. Which statement indicates an unexpected deviation from normal development?
- A. The infant is walking alone by 15 months.
- B. The infant waves good-bye by 7 months.
- C. The infant rolls from the tummy to the side at 12 months.
- D. The infant transfers a toy from one hand to the other at age 9 months.
Correct Answer: C
Rationale: Rolling tummy to side should occur by 6 months; delay to 12 months is concerning. Other milestones are age-appropriate or expected later.
A client who is taking tranylcypromine sulfate requests information about foods that are acceptable to eat while taking the medication. Which foods are safe to consume while taking this medication?
- A. Yogurt
- B. Raisins
- C. Oranges
- D. Smoked fish
Correct Answer: C
Rationale: Tranylcypromine sulfate is classified as a monoamine oxidase inhibitor (MAOI); as such, tyramine-containing food should be avoided. Oranges are permissible. Types of food to be avoided include—but are not limited to—yogurt, raisins, and smoked fish. Additionally, beer, wine, caffeinated beverages, pickled meats, yeast preparations, avocados, bananas, and plums are to be avoided.