Ati Nur 209 Reproductive Health Exam
Ati Nur 209 Reproductive Health Exam
Total Questions : 59
Showing 10 questions Sign up for moreWhich of the following clients would the nurse report as a suspected abuse case?
Explanation
A. A 10-year-old with a burn on the palm of the hand: This could potentially be accidental, for example, from touching a hot surface. However, while it requires further investigation, it is not as strongly indicative of abuse as the given option.
B. A 6-year-old with splash burns on the front torso: These burns could result from accidentally spilling hot liquids. Though it raises concern, it often indicates an accident rather than abuse unless accompanied by other suspicious signs.
C. A 4-year-old with circular abrasions around the wrists: This is highly suspicious of abuse because circular abrasions can indicate that the child may have been tied or restrained, which is not typical of accidents or normal play.
D. A 2-year-old with a large bruise on the forehead: This type of injury is common in young children who are prone to falls and bumps. It might not immediately suggest abuse without additional context.
A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?
Explanation
A. Keep the newborn in a well-lit nursery: A well-lit nursery can overstimulate a preterm newborn. Preterm infants benefit more from a dim, quiet environment that mimics the womb.
B. Cluster the newborn's care activities: This helps minimize disruptions to the newborn’s rest periods, which is crucial for their growth and neurodevelopment. Clustering care reduces stress and promotes better sleep cycles.
C. Position the newborn to promote extension of muscles: Preterm infants generally benefit from a flexed position, which is more comforting and developmentally appropriate, rather than promoting muscle extension.
D. Use fingertips when calming the newborn: Using fingertips might be too stimulating for a preterm newborn. Instead, a gentle, whole-hand touch is often more comforting and less likely to cause overstimulation.
The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?
Explanation
A. Establish IV access: Although important for hydration and medication administration, it is not the immediate priority when assessing the fetal condition.
B. Assess the client's vital signs: While important, the immediate assessment of fetal well-being takes precedence to ensure there is no fetal distress.
C. Obtain fetal heart rate: This is crucial to assess the fetus’s condition immediately. Monitoring the fetal heart rate can identify any signs of distress and determine if urgent interventions are necessary.
D. Perform a sterile vaginal exam: This should follow the fetal heart rate assessment to check for labor progress and any complications, but it is not the first priority.
The nurse is caring for a client who is being admitted to the hospital with a neurocognitive disease due to Alzheimer's disease. Which action by the nurse is the priority?
Explanation
A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.
A 9-year-old client with oppositional defiant disorder (ODD) has been referred to a child psychologist due to frequent outbursts and defiant behavior at home and school. Which of the following interventions should the nurse prioritize to help manage the child's behavior effectively?
Explanation
A. Use physical restraints during severe outbursts to ensure safety: Restraints should only be used as a last resort and are not an effective or ethical primary strategy for managing behavior in children with ODD.
B. Assign daily chores that are challenging to encourage discipline: Assigning overly challenging chores may lead to frustration and non-compliance, exacerbating behavioral issues rather than helping.
C. Encourage solitary play to reduce social stressors: Isolating the child may worsen feelings of exclusion and does not address the need for social skills development and appropriate behavior in social contexts.
D. Put into practice consistent consequences for rule-breaking behavior: Consistency in consequences helps the child understand boundaries and the importance of following rules, which is crucial for managing behavior in ODD.
A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following Information should the nurse manager include in the teaching? (Select all that apply.)
Explanation
A. Stand directly in front of the client when talking: Standing directly in front of an agitated client can be seen as confrontational and might escalate the situation. It is better to stand at an angle and maintain a non-threatening posture.
B. Avoid wearing necklaces during client care: Wearing necklaces or other loose accessories can pose a safety risk if a client becomes aggressive and tries to grab or pull them, potentially causing injury.
C. Provide immediate verbal feedback for escalating behavior: Immediate feedback can help de-escalate potentially aggressive behavior by addressing issues before they become more serious. It also reinforces appropriate behavior and sets clear boundaries.
D. Bring security with you for all client interactions: Bringing security for all interactions is impractical and can create an atmosphere of distrust. Security should be involved only when there is a credible risk of violence.
E. Review the layout of the facility: Understanding the layout of the facility, including exits and potential hazards, helps in planning for safe interactions and knowing escape routes if a situation escalates.
A nurse is caring for a client diagnosed with anorexia nervosa and over exercises to avoid gaining weight. Which of the following should be the appropriate action by the nurse?
Explanation
A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding is likely to increase feelings of guilt and shame, which can exacerbate the disorder. A supportive and empathetic approach is more beneficial.
B. Praise the client for looking at herself in a mirror: This could reinforce a negative preoccupation with body image, which is a significant aspect of anorexia nervosa. Encouraging healthy coping mechanisms is more appropriate.
C. Restrict the client from being weighed: While it is important to manage weight monitoring carefully, outright restriction without addressing the underlying issues can increase anxiety and resistance to treatment.
D. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: This helps the client develop healthier coping strategies and provides support in managing the urge to overexercise, promoting therapeutic engagement.
A new student nurse is learning about Mental health. Which of the following should be stated as representation of a nursing intervention at the tertiary level of prevention in mental health?
Explanation
A. Implementing stress management workshops for employees in a workplace: This is an example of primary prevention, which aims to reduce the risk of mental health issues by promoting healthy behaviors and coping mechanisms.
B. Promoting mental health awareness and education in the community: This also falls under primary prevention, focusing on reducing the incidence of mental health issues through education and awareness.
C. Providing counseling and therapy to individuals with diagnosed mental health disorders: This represents tertiary prevention, which focuses on managing and mitigating the impact of existing mental health conditions to improve quality of life and prevent complications or deterioration.
D. Conducting mental health screenings in schools to identify students at risk for mental health issues: This is a form of secondary prevention, which involves early identification and intervention to prevent the progression of mental health issues.
A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?
Explanation
A. "Apply cold compresses when your child expresses pain." Cold can cause vasoconstriction, which may precipitate a sickle cell crisis by reducing blood flow to the extremities, thus increasing the risk of sickling of red blood cells. Warm compresses are recommended to help alleviate pain by promoting blood flow.
B. "Restrict outdoor play activity to 1 hour per day." While it's important to monitor physical activity to avoid overexertion, restricting outdoor play to a specific time frame without considering other factors like hydration and rest isn't the right approach. Physical activity is important but should be balanced with adequate hydration and rest.
C. "Monitor your child's temperature daily." While monitoring temperature is important, it isn't specifically critical on a daily basis unless there is a suspicion of infection. The primary focus should be on hydration and recognizing signs of infection.
D. "Offer fluids to your child multiple times every day." Hydration is crucial for children with sickle cell anemia as it helps to prevent sickling of cells by maintaining good blood flow and preventing dehydration, which can trigger a crisis.
A client arrives for her first prenatal appointment.
What is the correct way for the nurse to document the GTPAL for this client?
Explanation
- G: 4 pregnancies (2017 spontaneous abortion, 2018 twins with one demise, 2020 NSVD, and the current pregnancy)
- T: 2 term births (2020 and 2022)
- P: 1 preterm birth
- A: 1 abortion/miscarriage (2017 spontaneous abortion)
- L: 4 living children (twins from 2018 and the child born in 2020)
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