Health Promotion and Maintenance

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Sample questions from Health Promotion and Maintenance

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.During a community clinic visit, a 15-year-old who has type 1 diabetes says, "I skip lunch insulin when I have soccer because I do not want to go low." The adolescent is alert, with glucose 248 mg/dL and blood ketones negative. Which action should the nurse take first?

   • A.Ask the parent to supervise every insulin dose, including at school.
   • B.Tell the adolescent to omit the lunch dose on all days with afternoon exercise.
   • C.Refer the adolescent to the emergency department for treatment of hyperglycemia.
   • D.Ask the adolescent to describe the insulin plan used on practice days and any recent hypoglycemia.

   Rationale: Assessing the adolescent's current plan and experience identifies the specific knowledge or regimen problem before education is tailored. Routine insulin omission can worsen hyperglycemia, and transferring all responsibility to the parent does not support developmentally appropriate self-management. With no ketones or acute symptoms, emergency referral is not the priority; the nurse should next collaborate on a safe exercise and insulin plan.

2. 2.At change of shift in a pediatric clinic, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 12-year-old with a new ankle sprain who reports pain of 6 on a 0-to-10 scale
   • B.A 2-month-old with a temperature of 38.1 C (100.6 F) who is feeding less than usual
   • C.A 6-year-old with asthma whose oxygen saturation is 95% after using a prescribed rescue inhaler
   • D.A 16-year-old with acne who requests information about an over-the-counter product

   Rationale: A fever in an infant younger than 3 months requires prompt assessment because serious infection may initially present with few other signs. The child with asthma has improved oxygenation after the rescue medication, while the sprain and acne concerns are not as time-sensitive. Addressing the infant first supports timely escalation and appropriate family guidance.

3. 3.Refer to the client's chart. Which actions should the nurse take now to coordinate care and reduce the risk of injury? Select all that apply.

   • A.Keep the client upright and remain with the client while arranging the urgent assessment.
   • B.Notify the provider promptly of the declining oxygen saturation and increased work of breathing.
   • C.Wait for the scheduled 1100 respiratory treatment because the client has a history of chronic lung disease.
   • D.Request an urgent respiratory assessment and prepare to implement prescribed oxygen or other escalation measures.
   • E.Ask the nursing assistant to reassess the client's respiratory status in 30 minutes and report any change.

   Rationale: The fall in SpO2 from 94% to 88%, respiratory rate increase from 20 to 28/min, and new accessory muscle use at 1000 indicate acute deterioration, so the provider and an appropriate clinician must be engaged now. Keeping the client upright and not leaving the client alone supports breathing and safety during escalation. Delegating reassessment of an unstable client to an assistant or waiting for the scheduled treatment delays assessment and intervention.

4. 4.In a home health visit, a 74-year-old taking warfarin for atrial fibrillation reports eating fewer vegetables since starting a new diet and has an INR of 4.6 (therapeutic range 2.0-3.0). The client denies bleeding and has stable vital signs. Which action is most appropriate?

   • A.Ask the client to take an extra dose of warfarin tomorrow to prevent a low INR.
   • B.Have the client wait until the next routine appointment because there is no bleeding.
   • C.Contact the anticoagulation prescriber promptly to report the INR and dietary change and obtain instructions.
   • D.Tell the client to stop eating all foods containing vitamin K.

   Answer and rationale are in the full material.

5. 5.A parent of a 4-year-old asks the clinic nurse whether the child should receive a measles, mumps, and rubella vaccine today. The child has a mild runny nose, temperature 37.2 C, and no history of vaccine reaction or immunocompromise. Which response is best?

   • A.The mild illness without fever does not usually require delaying the vaccine; the nurse should verify the immunization record and screen for contraindications.
   • B.The vaccine should be withheld because live vaccines are contraindicated in all children younger than 5 years.
   • C.The child should receive an antibiotic before vaccination to prevent complications.
   • D.The vaccine should be postponed until the runny nose has completely resolved.

   Answer and rationale are in the full material.