Student Exam Results

Student Information
Last Name: lazaro Reference:
First Name: briselda
Exam: RN Lesson 3 Posttest Total Attempts: 1 Total Submitted Attempts : 1 Mark: 85 %
Reference:
Exam Name: RN Lesson 3 Posttest

Objective: RN Lesson 3 Posttest - Health Promotion and Maintenance Student Mark for this Objective: 85% Correct Responses: 17 / 20
Correct (Ref: )A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses
concern that the client seems depressed. The nurse should initially focus assessment by using which approach?
Learner Response: B) Observe the client's affect and behavior
Correct Response: B) Observe the client's affect and behavior
Feedback: Although it is important to begin an assessment for depression immediately, the assessment should not be
aggressively intrusive unless the nurse has confirmed the observation of the family member or if there are
concerns about the risk of suicide.
Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis:
Elsevier.
Clark, M.J. (2003). Community health nursing: caring for populations. (4th ed.). Upper Saddle River, New
Jersey: Prentice Hall.

Correct (Ref: )The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the
child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?
Learner Response: D) Accept their feelings without judgment
Correct Response: D) Accept their feelings without judgment
Feedback: Parents often blame themselves for their child's illness. Feeling helpless and angry is normal and these
feelings must be accepted.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA:
Thompson Delmar Learning.

Correct (Ref: )The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury.
Which statement is true concerning long bone fractures in children?
Learner Response: B) Epiphyseal fractures often interrupt a child's normal growth pattern
Correct Response: B) Epiphyseal fractures often interrupt a child's normal growth pattern
Feedback: The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause
growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An
epiphyseal fracture is serious because it can interrupt and alter growth.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Price, S.A. & Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th ed.). St.
Louis: Elsevier.

Correct (Ref: )When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?
Learner Response: D) During the preadolescent growth spurt
Correct Response: D) During the preadolescent growth spurt
Feedback: Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the
preadolescent growth spurt. It is more common in females than in males.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA:
Thompson Delmar Learning.

Correct (Ref: )A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has
not been following the prescribed diet. What would be the most appropriate nursing action?
Learner Response: C) Discuss diet with the client to learn the reasons for not following the diet
Correct Response: C) Discuss diet with the client to learn the reasons for not following the diet

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 Student Exam Results

Feedback: When new problems are identified, it is important for the nurse to collect accurate assessment data. Before
reporting findings to the provider, it is best to have a complete understanding of the client's behavior and
feelings as a basis for future teaching and intervention.
Smeltzer, S.C., & Bare, B.G. (2004). Medical surgical nursing. (10th ed.). Philadelphia: Lippincott Williams &
Wilkins.
Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis:
Elsevier.

Correct (Ref: )A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills
are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping
every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis?
Learner Response: A) Noncompliance related to medication side effects
Correct Response: A) Noncompliance related to medication side effects
Feedback: The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the
regimen due to side effects, not because of a lack of knowledge about the disease process.
Key, J.L., & Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th ed.). Philadelphia:
Elsevier.
Smeltzer, S.C., & Bare, B.G. (2004). Medical surgical nursing. (10th ed.). Philadelphia: Lippincott Williams &
Wilkins.

Correct (Ref: )The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant
until about 12 months of age?
Learner Response: A) Formula or breast milk
Correct Response: A) Formula or breast milk
Feedback: Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA:
Thompson Delmar Learning.

Correct (Ref: )When teaching effective stress management techniques to a client 1 hour before surgery, which of the following
should the nurse recommend?
Learner Response: B) Deep breathing
Correct Response: B) Deep breathing
Feedback: Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a
short period pre-operatively.
Delaune, S. & Lander, P. (2002). Fundamentals in nursing: standards and practice. (2nd ed). Clinton Park,
New York: Delmar.
Smeltzer, S.C., & Bare, B.G. (2004). Medical surgical nursing. (10th ed.). Philadelphia: Lippincott Williams &
Wilkins.

Incorrect (Ref: )The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which
evaluation data would best measure learning?
Learner Response: B) Responses to verbal questions
Correct Response: D) Reported behavioral changes
Feedback: If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that
learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis:
Elsevier.

Correct (Ref: )The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?
Learner Response:
Correct Response:
Feedback:
B) Encourage the child to feed himself finger food
B) Encourage the child to feed himself finger food
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should
encourage increasingly independent activities of daily living that allow the toddler to assert his budding
sense of control.
Weber, J., & Kelley, J. (2003). Health assessment in nursing. (2nd ed.). Philadelphia: Lippincott Williams &
Wilkins.
Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis:
Elsevier.

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 Student Exam Results

Correct (Ref: )When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the
developmental needs of this age child?
Learner Response: D) Explain the surgery using a model of the heart
Correct Response: D) Explain the surgery using a model of the heart
Feedback: According to Piaget, the school age child is in the concrete operations stage of cognitive development.
Using something concrete, like a model will help the child understand the explanation of the heart surgery.
Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA:
Thompson Delmar Learning.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.

Correct (Ref: )The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
Learner Response: A) Hold a rattle
Correct Response: A) Hold a rattle
Feedback: The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA:
Thompson Delmar Learning.

Incorrect (Ref: )When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the
children participating in?
Learner Response: B) Playing with their own toys along side with other children
Correct Response: D) Playing cooperatively with other preschoolers
Feedback: Cooperative play is typical of the late preschool period.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Weber, J., & Kelley, J. (2003). Health assessment in nursing. (2nd ed.). Philadelphia: Lippincott Williams &
Wilkins.

Correct (Ref: )While the nurse is administering medications to a client, the client states "I do not want to take that medicine today."
Which of the following responses by the nurse would be best?
Learner Response: C) "Is there a reason why you don't want to take your medicine?"
Correct Response: C) "Is there a reason why you don't want to take your medicine?"
Feedback: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is
crucial to ensure that client needs are adequately identified in order to select the best nursing care
approaches. The nurse should try to discover the reason for the refusal which may be that the client has
developed untoward side effects.
Smeltzer, S.C., & Bare, B.G. (2004). Medical surgical nursing. (10th ed.). Philadelphia: Lippincott Williams &
Wilkins.
Delaune, S. & Lander, P. (2002). Fundamentals in nursing: standards and practice. (2nd ed). Clinton Park,
New York: Delmar.

Correct (Ref: )A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to
leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
Learner Response: D) Ask the client if the preference would be to remove the dentures in the operating room receiving area
Correct Response: D) Ask the client if the preference would be to remove the dentures in the operating room receiving area
Feedback: Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the
situation and fosters the client's sense of self-esteem and self-concept.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment &
management of clinical problems. St. Louis: Elsevier.
Smeltzer, S.C., & Bare, B.G. (2004). Medical surgical nursing. (10th ed.). Philadelphia: Lippincott Williams &
Wilkins.

Correct (Ref: )The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period.
She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse
calculate as the estimated date of delivery (EDD)?
Learner Response: D) December 23
Correct Response: D) December 23
Feedback: Naegele's rule states: Add 7 days and subtract 3 months from the first day of the last regular menstrual
period to calculate the estimated date of delivery.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Condon, M.C. (2004). Women's health, an integrated approach to wellness and illness. Upper Saddle River,
New Jersey: Prentice Hall.

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Correct (Ref: )A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the
pollution and crowding in southern California. The nurse explains that
Learner Response: A) such fantasies can gratify unconscious wishes or prepare for anticipated future events
Correct Response: A) such fantasies can gratify unconscious wishes or prepare for anticipated future events
Feedback: Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious
wishes.
Varcarolis, E. (2002). Foundations of psychiatry mental health nursing a clinical approach. (4th ed.).
Philadelphia: Elsevier.
Fontaine, K.L. (2003). Mental health nursing. (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Incorrect (Ref: )An appropriate treatment goal for a client with anxiety would be to
Learner Response: A) ventilate anxious feelings to the nurse
Correct Response: C) learn self-help techniques
Feedback: Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the
client to learn self-help techniques will assist in learning to cope with anxiety.
Delaune, S. & Lander, P. (2002). Fundamentals in nursing: standards and practice. (2nd ed). Clinton Park,
New York: Delmar.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A client states, "People think I'm no good, you know what I mean?" Which of these responses would be most
therapeutic?
Learner Response: C) "I'm not sure what you mean. Tell me a bit more about that."
Correct Response: C) "I'm not sure what you mean. Tell me a bit more about that."
Feedback: This therapeutic communication technique elicits more information, especially when delivered in an open,
non-judgmental fashion.
Delaune, S. & Lander, P. (2002). Fundamentals in nursing: standards and practice. (2nd ed). Clinton Park,
New York: Delmar.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and
becomes disoriented when away from home. Which statement would provide the best reality orientation for this
client?
Learner Response: D) "Good morning. You're in the hospital. I am your nurse Elaine Jones."
Correct Response: D) "Good morning. You're in the hospital. I am your nurse Elaine Jones."
Feedback: As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This
response establishes time, location and the caregiver's name.
Smeltzer, S.C., & Bare, B.G. (2004). Medical surgical nursing. (10th ed.). Philadelphia: Lippincott Williams &
Wilkins.
Clark, M.J. (2003). Community health nursing: caring for populations. (4th ed.). Upper Saddle River, New
Jersey: Prentice Hall.

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