When providing holistic care to a client, the nurse recognizes that which behaviors are necessary?

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Question 1 of 5

When providing holistic care to a client, the nurse recognizes that which behaviors are necessary?

Correct Answer: A

Rationale: Holistic care in nursing embraces the whole person mind, body, spirit requiring tailored approaches. Understanding and respecting each person's definition of health acknowledges their unique values, like viewing wellness as independence or spiritual peace, shaping care plans. Respecting responses to illness honors individual coping like stoicism or seeking support fostering trust. A standard health definition ignores this diversity, risking alienation, while calling health inactive contradicts its dynamic nature people actively pursue it. Holistic nursing uses models like the wellness wheel to integrate dimensions, ensuring care fits the client, not a mold. This flexibility enhances engagement, as when a nurse adapts teaching for a client valuing herbal remedies, strengthening outcomes by aligning with personal beliefs and experiences.

Question 2 of 5

A nurse provides care to clients of a community clinic that serves a large immigrant population. Which intervention reflects primary prevention for this group?

Correct Answer: B

Rationale: Primary prevention stops illness before it starts, vital for immigrants facing unique risks. Providing vaccinations like measles or flu shots builds immunity, preventing outbreaks in a group often under-vaccinated due to access or prior country norms, a top nursing action in clinics. Screening for tuberculosis is secondary, catching disease early, common in immigrant health but not preventive. Referring hypertension cases or teaching diabetic foot care is tertiary, managing existing conditions, not averting onset. Vaccinations align with primary prevention's proactive stance data shows they cut infectious disease rates in such populations addressing environmental and social vulnerabilities. Nursing leverages this to protect community health, ensuring immigrants, often in crowded settings, dodge preventable illnesses, a practical, impactful step for this clinic's focus.

Question 3 of 5

The parents of a healthy 6-year-old ask the nurse for advice about preventing obesity in their child. Which response reflects health promotion?

Correct Answer: A

Rationale: For a healthy 6-year-old, health promotion prevents obesity by fostering active habits limiting screen time and encouraging outdoor play boosts physical activity, burning calories and building muscle, key to avoiding weight gain at this age. Evidence links sedentary screen hours to childhood obesity; play counters it, aligning with nursing's focus on lifestyle over surveillance. Monthly weighing is secondary, tracking not preventing, and may stress the child. Multivitamins don't prevent obesity caloric balance does while annual cholesterol checks detect, not avert, issues. The nurse's reply promotes wellness through fun, practical steps like biking or tag tailored to a child's energy, ensuring long-term health without medicalizing a well kid, a cornerstone of pediatric nursing's preventive approach.

Question 4 of 5

The nurse notes small, pimple-like pustules all over the newborn's body. When charting the integumentary assessment of this newborn, which normal finding does the nurse note?

Correct Answer: C

Rationale: Small, pimple-like pustules on a newborn's body suggest erythema toxicum (C), a benign, self-limiting rash common in the first week of life, often with erythematous macules and pustules. Strawberry hemangiomas (A) are vascular growths, not pustular. Port-wine stains (B) are flat, purple birthmarks. Telangiectatic nevi simplex (D) are salmon-colored patches, not pustules. C is correct. Rationale: Erythema toxicum affects up to 70% of newborns, caused by an immune response, resolving without treatment, distinct from vascular or permanent lesions, aligning with normal neonatal skin findings.

Question 5 of 5

The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.

Correct Answer: D

Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.

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