Maternal And Child Nursing Care 5th Edition By London – Test Bank

Complete Test Bank With Answers

 

 

Sample Questions Posted Below

 

Chapter 5   Health Promotion for Women

1)Which client should the nurse document as exhibiting signs and symptoms of primary dysmenorrhea?

1. 17-year-old, has never had a menstrual cycle

2. 19-year-old, regular menses for 5 years that have suddenly become painful

3. 14-year-old, irregular menses for 1 year, experiences cramping every cycle

4. 16-year-old, had regular menses for 4 years, but has had no menses in 4 months

Answer:   3

Explanation:

1. This is primary amenorrhea, or the lack of menses.

2. Secondary dysmenorrhea is the sudden onset of pain and discomfort with menses.

3. Primary dysmenorrhea is when menstruation has been painful from the first menstrual cycle and consistently continues to be painful each month.

4. Secondary amenorrhea is the term used when a client has had regular cycles that cease.

Page Ref:   81

Cognitive Level:   Analyzing

Client Need/ Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:   5.2 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome.

MNL Learning Outcome: 1.2.3. Explain the female reproductive cycle.

2)A client asks, “Is it okay for me to use a vaginal douche each day when I’m on my period?” How should the nurse respond?

1. “Douching should be avoided when you’re on your period.”

2. “Regular douching is necessary in order to promote good hygiene.”

3. “Using a douche each day will help prevent vaginal infections from occurring.”

4. “During your period, douching will help promote the flow of menstrual secretions.”

Answer:   1

Explanation:

1. Women should avoid douching during menstruation because the cervix is dilated to permit the downward flow of menstrual fluids from the uterine lining.

2. Douching as a hygiene practice is unnecessary because the vagina cleanses itself.

3. Douching washes away the natural mucus and upsets the vaginal flora, which can make the vagina more susceptible to infection.

4. During menstruation, douching may interfere with downward flow of menstrual fluids from the uterine lining.

Page Ref:   79

Cognitive Level:   Applying

Client Need/Sub:   Physiological Integrity/Reduction of Risk Potential

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:   5.1 Describe accurate information to be provided to girls and women so that they can implement effective self-care measures for dealing with menstruation.

MNL Learning Outcome: 1.2.3. Explain the female reproductive cycle.

3)What should the gynecology clinic nurse recommend for the client experiencing premenstrual syndrome (PMS)?

1. “Increase your consumption of red meat when you feel symptoms, and eat three large meals per day.”

2. “Engage in aerobic activity often throughout the month, and continue exercising when your symptoms begin.”

3. “Decrease your dietary intake of dairy and soy slightly during the month, and especially during your days of bleeding.”

4. “Eat more chocolate and drink more caffeine beginning a week prior to when your menstrual cycle bleeding should begin.”

Answer:   2

Explanation:

1. Decreased red meat consumption can be beneficial to reduce PMS symptoms, as will eating several small meals per day rather than three large meals.

2. Regular aerobic activity helps to decrease PMS symptoms.

3. 1200 mg of calcium per day can help decrease PMS symptoms. The calcium can either come from supplements or be obtained through dietary intake of dairy and soy products.

4. Chocolate and caffeine contain methylxanthines; therefore, intake of chocolate, coffee, and colas should be limited throughout the month.

Page Ref:   82

Cognitive Level:   Applying

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:   5.2 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome.

MNL Learning Outcome: 1.2.3. Explain the female reproductive cycle.

4)A client comes to the clinic complaining of severe menstrual cramps. She has never been pregnant, has been diagnosed with ovarian cysts, and has had an intrauterine device (IUD) for 2 years. What is the most likely reason for this client’s complaint?

1. Menorrhagia

2. Hypermenorrhea

3. Primary dysmenorrhea

4. Secondary dysmenorrhea

Answer:   4

Explanation:

1. Menorrhagia is excessive, profuse flow.

2. Hypermenorrhea is an abnormally long menstrual flow.

3. Primary dysmenorrhea is defined as cramps without underlying disease.

4. Secondary dysmenorrhea is associated with pathology of the reproductive tract and usually appears after menstruation has been established. Conditions that most frequently cause secondary dysmenorrhea include ovarian cysts and the presence of an intrauterine device.

Page Ref:   81

Cognitive Level:   Analyzing

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:   5.2 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome.

MNL Learning Outcome: 1.2.3. Explain the female reproductive cycle.

5)Which issues should the nurse consider when counseling a client on contraceptive methods? Select all that apply.

1. Age at menarche

2. Efficacy of the method

3. Future childbearing plans

4. Whether the client is a vegetarian

5. Cultural perspectives on menstruation and pregnancy

Answer:   2, 3, 5

Explanation:

1. Age at menarche has no impact on contraceptive method use.

2. Efficacy of contraceptive methods varies and must be considered when discussing contraception with clients. When pregnancy is medically contraindicated, high-efficacy methods (such as an IUD, hormonal methods, or sterilization) should be discussed with the client. When the client would like to avoid pregnancy at this time, but pregnancy is not medically contraindicated, lower-efficacy methods (such as diaphragm, cervical cap, or Today sponge) could be discussed.

3. If a client desires children in the future, sterilization methods would be inappropriate to discuss.

4. Vegetarianism has no impact on contraceptive method use.

5. Cultural and religious beliefs, practices, and sanctions must be considered when discussing contraception with clients in order to avoid insulting a client for whom a particular type of contraceptive method is prohibited by her background.

Page Ref:   82

Cognitive Level:   Applying

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:   5.3 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

MNL Learning Outcome: 6.1.2. Compare advantages, disadvantages, risk factors, and contraindications of contraception methods.

6)A client has decided to use the NuvaRing vaginal contraceptive ring as her method of contraception. Which statement suggests the client needs further instruction?

1. “When I store my replacement rings, I should keep them in my refrigerator.”

2. “The contraceptive ring provides a sustained release of low-dose contraceptive.”

3. “Every 3 months, I will need to remove the contraceptive ring and replace it with a new one.”

4. “I do not need to be examined in order to determine the contraceptive ring size that is correct for me.”

Answer:   3

Explanation:

1. Replacement rings should be kept in the refrigerator to maintain integrity.

2. The contraceptive ring provides a low-dose, sustained-release hormonal contraceptive.

3. The ring is left in place for 3 weeks and then removed for 1 week to allow for withdrawal bleeding.

4. One size of the NuvaRing fits virtually all women.

Page Ref:   89

Cognitive Level:   Analyzing

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care | NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome:   5.3 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

MNL Learning Outcome: 6.1.2. Compare advantages, disadvantages, risk factors, and contraindications of contraception methods.

7)Which client is not a good candidate for Depo-Provera (DMPA)?

1. One with a vaginal prolapse

2. One who weighs 200 pounds

3. One who wishes to breastfeed

4. One who wishes to get pregnant within 3 months

Answer:   4

Explanation:

1. There is no correlation between a vaginal prolapse and use of Depo-Provera.

2. There is no correlation between one’s weight and use of Depo-Provera.

3. Studies have proven there is no harm to a breastfed baby when a woman uses Depo-Provera.

4. Return of fertility after the use of Depo-Provera takes an average of 10 months.

Page Ref:   89

Cognitive Level:   Understanding

Client Need/Sub:   Physiological Integrity/Pharmacological and Parenteral Therapies

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment 

Learning Outcome:   5.3 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

MNL Learning Outcome: 6.1.2. Compare advantages, disadvantages, risk factors, and contraindications of contraception methods.

8)A 16-year-old girl asks, “Do I need to have a Pap smear just because I’m sexually active?” What is the nurse’s correct response?

1. “No, you do not need to be screened for cervical cancer until you are 21 years old.”

2. “Yes, all sexually active females should be screened for both cervical cancer and human papilloma virus (HPV).”

3. “Yes, all women under the age of 29 should be screened for both cervical cancer and human papilloma virus (HPV).”

4. “No, but you will need to begin your screenings for both cervical cancer and human papilloma virus (HPV) when you are 18 years old.”

Answer:   1

Explanation:

1. 2012 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend initiating cervical cancer screening at age 21.

2. Engaging in sexual activity is not an indication for routine cervical cancer or for HPV screening.

3. 2012 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend cervical cancer screening without HPV cotesting in women ages 21 to 29.

4. 2012 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend initiating cervical cancer screening at age 21.

Page Ref:   95

Cognitive Level:   Applying

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:   5.5 Identify basic gynecologic screening procedures indicated for well women.

MNL Learning Outcome: 6.2.1. Recognize client behaviors associated with the acquisition of sexually transmitted infections.

9)A nurse provides a client with instructions regarding breast self-examination (BSE). Which client statements indicate an understanding of detecting lumps in the breast? Select all that apply.

1. “I should inspect my breasts in a circular manner.”

2. “Knowing the texture and feel of my breasts is important.”

3. “I should perform BSE 1 week prior to the start of my period.”

4. “When I reach menopause, I will perform BSE every 2 months.”

5. “I should inspect my breasts while in a supine position, with my arms at my sides.”

Answer:   1, 2

Explanation:

1. Checking breasts in a circular manner, feeling all parts of the breast, provides adequate palpation and possible detection of lumps.

2. A woman who knows the texture and feel of her own breasts is far more likely to detect changes that develop.

3. BSE should be performed 1 week after the start of each menstrual period because hormonal levels are lowest and allow closer examination of softer breast tissue.

4. BSE should be performed monthly, on the same day each month, during menopause.

5. The breasts should be inspected while standing with arms at sides.

Page Ref:   93

Cognitive Level:   Analyzing

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome:   5.5 Identify basic gynecologic screening procedures indicated for well women.

MNL Learning Outcome: 1.2.2. Describe the structures and functions of the female reproductive system.

10)What is the best indicator that the client is experiencing menopause?

1. Hot flashes and night sweats

2. No menses for 8 consecutive months

3. High serum follicle-stimulating hormone (FSH) with low serum estrogen

4. Diagnosis of osteoporosis 4 months ago

Answer:   3

Explanation:

1. Although hot flashes and night sweats are common in menopause, laboratory values or 12 months of amenorrhea are better indicators.

2. Menopause is defined as 12 months of amenorrhea.

3. Examining serum levels of the hormones FSH and estrogen is a very accurate indication of menopause.

4. Menopause is not the only cause of osteoporosis; therefore, the diagnosis of osteoporosis 4 months ago is not an indicator of menopause.

Page Ref:   95

Cognitive Level:   Understanding

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:   5.6 Examine the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women.

MNL Learning Outcome: 6.1.1. Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.

11)A 63-year-old female client requests information about complementary and alternative therapies that promote wellness during menopause. Which therapy should the nurse recommend?

1. Soy for reducing insomnia symptoms

2. Non–weight-bearing exercise, such as swimming

3. Calcium intake of 600 mg per day to help prevent osteoporosis

4. Increased consumption of phytoestrogens for women with a history of endometriosis or fibroids

Answer:   1

Explanation:

1. Research suggests that isoflavones, which are found in soy, are effective in reducing symptoms of insomnia in postmenopausal women.

2. Weight-bearing exercises such as walking, jogging, tennis, and low-impact aerobics are encouraged in order to increase bone mass and decrease the risk of osteoporosis.

3. Perimenopausal and postmenopausal women are advised to have a calcium intake of at least 1200 mg per day. Most women require supplements to achieve this level.

4. Women who have endometriosis or fibroids should be cautioned about the use of phytoestrogens.

Page Ref:   97

Cognitive Level:   Applying

Client Need/Sub:   Physiological Integrity/Pharmacological and Parenteral Therapies

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.17. Develop a beginning understanding of complementary and alternative modalities and their role in health care | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:   5.6 Examine the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women.

MNL Learning Outcome: 6.1.1. Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.

12)The nurse is presenting a session on intimate partner violence. Which statement indicates a need for further education?

1. “The ‘honeymoon period’ follows an episode of violence.”

2. “Everyone experiences anger and hitting in a relationship.”

3. “Abusers can be either husbands or boyfriends or wives or girlfriends.”

4. “My daughter is not to blame for the violence in her marriage.”

Answer:   2

Explanation:

1. An acute episode of battering is followed by the tranquil phase, or honeymoon period, when the abuser is often repentant and promising never to abuse the victim again. In some cases, the honeymoon period is the only time there is a lack of building tension.

2. Violence is not a normal part of intimate relationships. This statement indicates that the client has likely been a victim of domestic violence.

3. Abusers can be spouses or boyfriends or girlfriends. Intimate partner violence can be experienced in any intimate relationship, regardless of whether the couple is straight, gay, or lesbian, and both within marriage and outside of marriage.

4. The victims of violence are not the cause of the violence. Abusers are responsible for their violent behavior. Avoiding blaming and shaming of victims of domestic violence is important to establish a therapeutic relationship.

Page Ref:   98

Cognitive Level:   Analyzing

Client Need/Sub:   Psychosocial Integrity

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care | NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome:   5.7 Describe the phases of the cycle of violence.

MNL Learning Outcome: 6.1.3. Determine strategies to assist the victim of domestic violence.

13)When a woman who has been raped is admitted to the emergency department, which nursing intervention has priority?

1. Contact family members.

2. Create a safe, secure atmosphere for the woman.

3. Assure the woman that everything will be all right.

4. Explain exactly what will need to be done to preserve legal evidence.

Answer:   2

Explanation:

1. Contacting family members is not the top priority and can wait until a safe environment is established.

2. The first priority in caring for a survivor of a sexual assault is to create a safe, secure atmosphere that will allow the woman to process what has happened.

3. Assuring the woman that everything will be all right is not the top priority and is giving false promise.

4. Explaining exactly what will need to be done to preserve legal evidence is not the top priority.

Page Ref:   101

Cognitive Level:   Applying

Client Need/Sub:   Psychosocial Integrity

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-client relationship| NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:   5.9 Discuss the nurse’s role in screening and caring for women who have experienced domestic violence or rape.

MNL Learning Outcome: 6.1.3. Determine strategies to assist the victim of domestic violence.

14) A middle school student comes to the nurse’s office concerned about her menstrual flow. What should the nurse include when discussing menstruation with this student? Select all that apply.

1. A tub bath is helpful to promote blood flow and reduce cramping.

2. Show a variety of pads and tampons available for the student to use.

3. A fishy odor experienced during menstruation is expected and normal.

4. Demonstrate that the volume of blood lost during menstruation is about 1 to 2 ounces.

5. Wash the hands before and after using any feminine hygiene products for menstruation.

Answer: 1, 2, 4, 5
Explanation:

1. A long, leisurely soak in a warm tub promotes menstrual blood flow and relieves cramps by relaxing the muscles.

2. If working with teens and preteens, keeping a variety of pads and tampons on hand helps these young girls become familiar with the options available for dealing with menstruation.

3. Conditions such as vaginitis produce a foul-smelling discharge that women often describe as having a “fishy” odor. This is not expected or normal.

4. The average flow is approximately 25 to 60 mL per period.

5. Because of the potential for developing an infection, a woman should wash her hands before inserting a fresh tampon and should avoid touching the tip of the tampon when unwrapping it or before insertion. Hand washing should also occur after using the commode.

Page Ref:   79

Cognitive Level:   Applying

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care | NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome:   5.1 Describe accurate information to be provided to girls and women so that they can implement effective self-care measures for dealing with menstruation.

MNL Learning Outcome: 1.2.3. Explain the female reproductive cycle.

15) During a health interview the nurse determines that a client contemplating pregnancy would benefit from teaching on preconception health measures. What information did the nurse use to make this clinical determination? Select all that apply.

1. Smokes one half of a pack per day of cigarettes

2. Works in an industrial plant

3. Drinks decaffeinated coffee

4. Drinks 4 ounces red wine every evening

5. Takes over-the-counter antacids as needed

Answer: 1, 2, 4, 5
Explanation:

1. One preconception health measure is smoking cessation.

2. One preconception health measure is identifying environmental hazards.

3. Avoiding caffeine several months before conception is a preconception health measure.

4. One preconception health measure is alcohol intake.

5. One preconception health measure is the use of over-the-counter medications.

Page Ref:   92

Cognitive Level:   Analyzing

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care | NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning

Learning Outcome:   5.4 Summarize major health measures to address in providing preconception counseling.

MNL Learning Outcome: 1.1.3. Relate various factors to their effect on pregnancy outcomes.

16) During a wellness visit a young adult client asks for information regarding weight management and exercise prior to pregnancy. What should the nurse explain to this client? Select all that apply.

1. Reduce the intake of complex carbohydrates.

2. Achieve normal weight for height before conceiving.

3. Begin an exercise program a month before conceiving.

4. Select an exercise program to be followed throughout the pregnancy.

5. Reduce weight to below normal for height to compensate for pregnancy weight gain.

Answer: 3, 4
Explanation:

1. No particular food group should be avoided for adequate nutritional status.

2. Before conception, it is advisable for the woman to be at an average weight for her body build and height.

3. A woman is advised to establish a regular exercise plan beginning at least 3 months before she plans to attempt to become pregnant.

4. The exercise should be one she enjoys and will continue.

5. Weight should not be reduced to an unhealthy level before conceiving.

Page Ref:   92

Cognitive Level:   Applying

Client Need/Sub:   Health Promotion and Maintenance

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care | NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome:   5.4 Summarize major health measures to address in providing preconception counseling.

MNL Learning Outcome: 1.1.3. Relate various factors to their effect on pregnancy outcomes.

17) The nurse suspects that a home care client is experiencing the tension-building phase within the cycle of violence. What observations caused the nurse to make this clinical determination? Select all that apply.

1. Spouse ignoring the client

2. Spouse yelling at the client

3. Client asking the nurse to leave

4. Client apologizing to the spouse

5. Spouse throwing items at the client

Answer: 2, 3, 4
Explanation:

1. During the tension-building phase of the cycle of violence the batterer demonstrates power and control. Ignoring the client could occur during the tranquil loving phase.

2. During the tension-building phase of the cycle of violence the batterer demonstrates power and control which is characterized by anger and arguing.

3. During the tension-building phase of the cycle of violence the batterer demonstrates power and control; however, the woman may believe the escalation of anger can be controlled by her own actions. Asking the nurse to leave would be a controllable action.

4. During the tension-building phase of the cycle of violence the batterer demonstrates power and control; however, the woman may blame herself and apologize for her actions.

5. Throwing things at the client would occur during the acute battering incident.

Page Ref:   98

Cognitive Level:   Analyzing

Client Need/Sub:   Psychosocial Integrity

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.12. Create a safe environment that results in high quality client outcomes | NLN Competencies: Quality and Safety; Practice; Encourage clients and families to communicate their observations and concerns regarding safety | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:   5.7 Describe the phases of the cycle of violence.

MNL Learning Outcome: 6.1.3. Determine strategies to assist the victim of domestic violence.

18) The nurse is preparing a community education session on the stages of the rape trauma syndrome. In which order should the nurse explain the phases of this syndrome?

1. Buys a weapon

2. Advocates for others

3. Desires revenge and feels guilty

4. Changes email address and phone number

Answer: 3, 1, 4, 2
Explanation:

1. Buying a weapon occurs during the outward adjustment phase.

2. Advocating for others occurs during the integration and recovery phase.

3. Desiring revenge and feeling guilty occurs during the acute phase.

4. Changing communication methods occurs during the reorganization phase.

Page Ref:   101

Cognitive Level:   Applying

Client Need/Sub:   Psychosocial Integrity

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care | NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning

Learning Outcome:   5.8 Identify the phases of the rape trauma syndrome.

MNL Learning Outcome: 6.1.3. Determine strategies to assist the victim of domestic violence.

19) During a group session of rape trauma survivors the nurse notes that one participant is in the reorganization phase of recovery. What did this participant demonstrate to cause the nurse to make this decision? Select all that apply.

1. Blames the assailant for the rape

2. Asks what she did to deserve the attack

3. Explains about constantly reliving the rape

4. Asks when the nightmares are going to stop

5. Talks about having one-night stands after bar hopping

Answer: 3, 4, 5
Explanation:

1. Blaming the assailant is a behavior consistent with the integration and recovery phase.

2. Asking what she did to deserve the attack is a characteristic of the acute phase.

3. Constantly reliving the rape or having flashbacks is a characteristic of the reorganization phase.

4. Experiencing nightmares is a characteristic of the reorganization phase.

5. Risky sexual behavior is a characteristic of the reorganization phase.

Page Ref:   101

Cognitive Level:   Analyzing

Client Need/Sub:   Psychosocial Integrity

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:   5.8 Identify the phases of the rape trauma syndrome.

MNL Learning Outcome: 6.1.3. Determine strategies to assist the victim of domestic violence.

20) The emergency room nurse is caring for a victim of sexual assault. What pharmacologic intervention should the nurse prepare to discuss with the victim? Select all that apply.

1. Prophylactic analgesics

2. Postcoital contraceptive therapy

3. Prophylactic immunizations for tetanus

4. Postexposure prophylaxis with HIV antiviral medications

5. Prophylactic treatment for sexually transmitted infections (STIs)

Answer: 2, 4, 5
Explanation:

1. Pain medications are not routinely required for this situation.

2. Postcoital contraceptive therapy should be offered to the victim.

3. Prophylactic tetanus immunization is not routinely required for this situation.

4. Postexposure prophylaxis with HIV antiviral medications should be offered to the victim.

5. Prophylactic treatment for STIs should be offered to the victim.

Page Ref:   101

Cognitive Level:   Applying

Client Need/Sub:   Physiological Integrity: Pharmacological and Parenteral Therapies

Standards:   QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:   5.9 Discuss the nurse’s role in screening and caring for women who have experienced domestic violence or rape.

MNL Learning Outcome: 6.1.3. Determine strategies to assist the victim of domestic violence.

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