care across the Lifespan Prep U Final exam

Whats a normal baby heart range?

110-160

In what age group would a nurse expect to assess the most rapid respiratory rate? older adults , middle adults , adolescents , infants

Infants Explanation- The normal infant's chest is small and the airways are short. There are fewer and smaller alveoli in infants. As a result, the respiratory rate is more rapid in infants than in individuals of any other age.

In what age group would a nurse expect to assess the most rapid respiratory rate?

Newborn explanation-For a newborn, a pulse rate of 80 to 180 beats/minute is considered normal. A normal rate for a 10-year-old is 75 to 110, an adolescent is 60 to 100 (13-19), and an adult is 60 to 100.

The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor? a. a normal pattern in infants of this age b. the need for an apnea monitor b. a need for close monitoring for the mother c. the need for a chest radiograph

a Explanation: The infant is exhibiting periodic breathing, which is normal in infants of this age. The infant typically alternates short periods of rapid, louder respirations with periods of slower, quieter respirations.

A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. The mother says that her infant can't sit alone. a. "This is very abnormal. Your child must be sick." b. "Let's see about further developmental testing." c. "Don't worry, this is normal for her age." d. "Maybe you just haven't seen her do it."

b Explanation: Stating that further developmental testing is necessary is appropriate because at age 12 months a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Saying the infant's behavior is abnormal or suggesting that the mother hasn't seen her infant do these milestones isn't therapeutic and can cut off communication with the mother. Telling the mother that the infant's behavior is normal misleads the mother with false reassurance.

When developing a care plan for a hospitalized adolescent with acute lymphoblastic leukemia, the nurse considers psychosocial needs. Which activity is best suited to help this adolescent cope with a prolonged illness? a. Playing board games with friends. b. Keeping a journal and scrapbook. c. Writing letters each day to special friends. d. Creating a puppet show for smaller children.

b. According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from his family. An activity that helps the adolescent cope by maintaining their identity is creating a journal of memories and frustrations. Becoming industrious is the developmental task of the school-age child; achieving intimacy is the task of the young adult; and developing initiative is the task of the preschooler. Board games, creating a puppet show, and writing letters are good activities for this adolescent, but are not best for assiting with coping and meeting needs for personal identity.

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action? a. Call the pediatrician because this finding is dangerously high. b. Document this finding as on the low end of the normal range and plan to reassess. c. Document this finding as on the high end of the normal range and plan to reassess. d. Notify the charge nurse because this finding is on the low end of the normal range given the newborn's quiet-alert state.

c. Explanation: Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still within the normal range. It would be appropriate to reassess the client's heart rate because newborn heart rates can fluctuate depending on the state of consciousness/wakefulness, hunger, temperature, and especially if the newborn is moving or startled. It would be inappropriate to call the pediatrician or to notify the charge nurse at this time because the value is currently within the normal range.

A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child? a. Make sure the child does not touch the assessment equipment. b. Perform as many tasks as possible with the child lying on the examining table. c. Perform the blood pressure measurement last. d. Perform the assessments quickly while maintaining a serious demeanor.

c. The blood pressure reading is the most invasive procedure performed when measuring vital signs. If the nurse were to perform it first it may upset the child further and prevent obtaining the remainder of the vital signs. Allowing the child to touch the assessment equipment often helps the child be more relaxed for the remainder of the assessment. Lying on the exam table is not necessary for vital signs and will likely call more anxiety. Being quick with a serious demeanor does not help decrease the child's anxiety.

According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by: a. emphasizing the need to follow the facility regimen. b. allowing parents and siblings to visit frequently. c. arranging for tutoring in school work. d. encouraging peer visitation.

d Explanation: Peer visitation gives the adolescent an opportunity to continue along the path toward independence and identity. Knowledge of the facility regimen prepares the adolescent for upcoming procedures but doesn't affect development. To achieve a sense of identity, the adolescent must gain independence from family. Tutoring may help maintain a positive self-image relative to schoolwork but doesn't affect development.

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about what the baby can do physically right after birth. An accurate statement from you about neonatal ability would be which of the following? a. The neonatal period lasts from birth to six months b. The elimination of stool and urine has not yet begun c. The Braden scale is used to assess newborns d. The newborn can suck, swallow, sneeze, and yawn

d. explanation The neonate is assessed immediately after birth at one and five minutes using the Apgar scale. The neonatal period lasts from birth to 28 days. The physical characteristics and behaviors of normal neonates include active reflexes (Moro, stepping, and grasp), hand-to-mouth activity, sucking, swallowing, blinking, sneezing, and yawning. Stool and urine are eliminated by the newborn.

When completing an assessment of a healthy adolescent client, which measure would be most appropriate? a. Obtain a detailed account of the adolescent's prenatal and early developmental history. b. Discuss sexual preferences and behaviors with the parents present for legal reasons. c. Discuss the client's smoking with parents present in the room. d. Gather information from the parents and adolescent; then assess the adolescent in private.

d. Explanation: When assessing an adolescent, it is appropriate to obtain information first from the adolescent and parents and then interview the adolescent privately for additional information. Doing so helps to promote independence and responsibility for self-care. Obtaining prenatal and early developmental history information is usually not important for a healthy adolescent. In addition, this information typically would have already been obtained at an earlier age. No legal reason would prohibit the nurse from discussing sexuality with the adolescent without the parents present. Discussing smoking with the parents present in the room is inappropriate. If the adolescent smokes, the parents may be unaware, and the adolescent would lose trust in the nurse.

dementis vs delirium

dementia- Dementia describes various disorders that progressively affect cognitive function. Delirium- Delirium is a temporary state of confusion that can last from hours to weeks and resolves with treatment.