Question

A nurse is providing preconception counseling about folic acid for a client who is trying to conceive. Which of the following client responses indicates an understanding of the teaching?

Answer 1

Correct Answers:

"Folic acid will decrease the risk of neural tube defects."

Rationale :

💎Folic acid is essential during the preconception period and early pregnancy because it supports DNA synthesis and cell division.

💎Adequate intake (typically 400–800 mcg daily) significantly reduces the risk of neural tube defects (NTDs) such as spina bifida and anencephaly, which occur in the first month of pregnancy when the neural tube is forming.

💎Folic acid also plays a role in the formation of red blood cells, helping prevent maternal anemia, but its primary teaching point for preconception counseling is its role in NTD prevention.

💎Since neural tube closure occurs early (by the 4th week of gestation), supplementation must begin before conception and continue in early pregnancy for maximum protection.

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Answer 2

Correct Answers:

Hydralazine

Rationale :

💊 Hydralazine is a vasodilator used in pregnancy to manage severe hypertension associated with preeclampsia or eclampsia.

🩸 It lowers systemic vascular resistance without reducing placental blood flow, protecting the fetus.

⚠️ Other options: Misoprostol is for cervical ripening; Methylergonovine is contraindicated in hypertension because it raises BP; Terbutaline is a tocolytic used for preterm labor.

👶 Hydralazine helps reduce maternal complications (stroke, seizures) while promoting safer outcomes for both mother and fetus.

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Answer 3

Correct Answers:

Dressed inappropriately for the season

Rationale :

🧥 Neglect is the failure to provide basic needs like food, clothing, shelter, and medical care.

🥶 A child dressed inappropriately (e.g., thin clothing in winter) is a classic indicator of physical neglect.

🚫 Recurrent UTIs suggest sexual abuse, not neglect.

📉 Weight in the 50th percentile is normal and not a concern.

😶 Lack of reaction to frightening events may indicate emotional abuse or trauma, not physical neglect.

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Answer 4

Correct Answers:

Hepatomegaly

Rationale :

🩺 Vasoocclusive crisis occurs when sickled RBCs block blood flow, leading to ischemia and organ enlargement.

🩸 Hepatomegaly and splenomegaly may develop from repeated sickling and sequestration of cells in organs.

🚫 Hemoglobin of 14.5 g/dL is normal; in sickle cell, hemoglobin is usually lower due to chronic anemia.

💧 Increased urination isn’t typical of vasoocclusive crisis but may occur in renal impairment.

👁️ Periorbital edema is more associated with renal conditions, not sickle crisis.

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Answer 5

Correct Answers:

Shingles vaccine is recommended for clients at 50 years old.

Rationale :

💉 The recombinant zoster vaccine (RZV, Shingrix) is recommended for adults ≥50 years old to prevent shingles.

🦠 Tetanus booster is every 10 years, not 5.

🫁 Pneumococcal vaccine (PCV or PPSV) is usually recommended starting at 65 years, unless chronic illness is present earlier.

❌ Influenza vaccine is yearly, regardless of age over 65.

👵 Teaching at age 50 is critical for preventive health as immune response begins to decline.

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Answer 6

Correct Answers:

Eat foods at colder temperatures.

Rationale :

🥗 Eating cold or room temperature foods reduces odors that may worsen nausea.

🚱 Drinking large amounts of water with meals can worsen nausea—fluids should be taken between meals.

❌ Avoiding all unhealthy foods isn’t the focus; instead, tolerated small frequent meals are encouraged.

🥛 Dairy foods are not routinely contraindicated; some women may tolerate them well.

🌸 Teaching includes rest, hydration, antiemetics if prescribed, and small, bland meals to reduce symptoms.

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Answer 7

Correct Answers:

Loss of depth perception

Rationale :

🎯 Right-hemispheric strokes often cause visual-spatial deficits such as poor depth perception, disorientation, and difficulty judging distance.

🎯Clients may also demonstrate impulsivity, poor judgment, and neglect of the left side (unilateral neglect).

🎯 Depression and slow, cautious behavior are more typical of left-hemispheric strokes.

🎯 Aphasia (difficulty with language) also usually results from left-hemispheric involvement.

🎯 Depth perception loss places clients at higher risk of falls and injury, making safety precautions essential.

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Answer 8

Correct Answers:

Ask the client questions requiring a "yes" or "no" response.

Rationale :

🙋 Yes/no questions simplify communication and reduce frustration in clients with cognitive decline, helping them participate in decision-making.

🙋 Hand gestures and nonverbal cues are actually encouraged, as they support comprehension when verbal ability decreases.

🙋 Giving three instructions at once is overwhelming — clients should receive one short, simple instruction at a time.

🙋 Nurses should not assume the client cannot understand; instead, use clear, calm, supportive communication to maximize preserved abilities.

🙋This strategy maintains dignity and helps the client feel respected while promoting cooperation in care.

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Answer 9

Correct Answers:

Take a stool softener.

Rationale :

💊Chemotherapy often causes constipation due to reduced activity, poor appetite, and opioid use for pain.

💊A stool softener helps prevent straining and supports bowel regularity.

💊Aspirin should be avoided because of bleeding risk with thrombocytopenia.

💊Heat to bruises may worsen bleeding; decreased fiber worsens constipation.

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Answer 10

Correct Answers:

Situational crisis

Rationale :

🌪️ Situational crises are triggered by unexpected life events (illness, loss of independence, accidents).

🌪️ This client’s loss of independence and need for rehab after living alone is a sudden change requiring adaptation.

🌪️ Adventitious crises = disasters/trauma; psychopathologic = mental illness; psychiatric emergency = immediate danger.

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RN Concept based Assessment Level 3 with NGN Sept

No.

1 :
A nurse is providing preconception counseling about folic acid for a client who is trying to conceive. Which of the following client responses indicates an understanding of the teaching?

2 :
A nurse is caring for a client who is at 37 weeks of gestation and has a history of eclampsia. Which of the following medications should the nurse expect the provider to prescribe to decrease the client's blood pressure?

3 :
A school nurse is assessing a 6-year-old child who reports physical neglect. Which of the following findings should the nurse expect?

4 :
A nurse is assessing a school-age child who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following findings should the nurse expect

5 :
A nurse is providing teaching with a 50-year-old client about immunization recommendations to promote wellness. Which of the following instructions should the nurse include in the teaching?

6 :
A nurse is providing teaching to a client who is experiencing hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse in an emergency department is assessing a client who has experienced a right hemispheric stroke. Which of the following findings should the nurse expect?

8 :
A nurse in a long-term care facility is planning care for a client who has advanced Alzheimer's disease. Which of the following interventions should the nurse plan to use when communicating with the client?

9 :
A nurse is providing discharge teaching for a client who has non-Hodgkin's lymphoma and will be receiving outpatient chemotherapy. Which of the following instructions should the nurse include?

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RN Concept based Assessment Level 3 with NGN Sept

No.

1 : A nurse is providing preconception counseling about folic acid for a client who is trying to conceive. Which of the following client responses indicates an understanding of the teaching?

2 : A nurse is caring for a client who is at 37 weeks of gestation and has a history of eclampsia. Which of the following medications should the nurse expect the provider to prescribe to decrease the client's blood pressure?

3 : A school nurse is assessing a 6-year-old child who reports physical neglect. Which of the following findings should the nurse expect?

4 : A nurse is assessing a school-age child who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following findings should the nurse expect

5 : A nurse is providing teaching with a 50-year-old client about immunization recommendations to promote wellness. Which of the following instructions should the nurse include in the teaching?

6 : A nurse is providing teaching to a client who is experiencing hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching?

7 : A nurse in an emergency department is assessing a client who has experienced a right hemispheric stroke. Which of the following findings should the nurse expect?

8 : A nurse in a long-term care facility is planning care for a client who has advanced Alzheimer's disease. Which of the following interventions should the nurse plan to use when communicating with the client?

9 : A nurse is providing discharge teaching for a client who has non-Hodgkin's lymphoma and will be receiving outpatient chemotherapy. Which of the following instructions should the nurse include?

1 :
A nurse is providing preconception counseling about folic acid for a client who is trying to conceive. Which of the following client responses indicates an understanding of the teaching?

2 :
A nurse is caring for a client who is at 37 weeks of gestation and has a history of eclampsia. Which of the following medications should the nurse expect the provider to prescribe to decrease the client's blood pressure?

3 :
A school nurse is assessing a 6-year-old child who reports physical neglect. Which of the following findings should the nurse expect?

4 :
A nurse is assessing a school-age child who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following findings should the nurse expect

5 :
A nurse is providing teaching with a 50-year-old client about immunization recommendations to promote wellness. Which of the following instructions should the nurse include in the teaching?

6 :
A nurse is providing teaching to a client who is experiencing hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse in an emergency department is assessing a client who has experienced a right hemispheric stroke. Which of the following findings should the nurse expect?

8 :
A nurse in a long-term care facility is planning care for a client who has advanced Alzheimer's disease. Which of the following interventions should the nurse plan to use when communicating with the client?

9 :
A nurse is providing discharge teaching for a client who has non-Hodgkin's lymphoma and will be receiving outpatient chemotherapy. Which of the following instructions should the nurse include?