HA POSSIBLE FINAL QUESTIONS
A 4-year-old boy is brought to the emergency department by his parents, who state that he has been crying and saying his ìtummy hurts.î Which method would be most appropriate for the nurse to initially assess the problem? A) Ask the child to point with one finger where it hurts. B) Inspect, palpate, percuss, and then auscultate the abdomen. C) Determine the time and character of the child's last bowel movement. D) Ask the child to describe the character of his pain.
A
A client at 26 weeks' gestation appears at the clinic for her first prenatal visit. During the health interview, she states that she has been a habitual cocaine user. The nurse understands that this client is at risk for which of the following? A) Abruptio placenta B) Thrombophlebitis C) Placenta previa D) Gestational diabetes
A
A client who is at 23 weeks' gestation tells the nurse, "I just burn up all the time. I can't even sleep with any covers on me!" The nurse explains to the client that heat intolerance during pregnancy is primarily due to which physiologic change? A) Increased basal metabolic rate B) Decreased sweat gland activity C) Increase in maternal blood volume D) Stretching of abdominal muscles
A
A nurse is having difficulty getting a 14-year-old child to ìopen upî during the health interview. What strategy is most likely to enhance the nurse's communication with this child? A) Give the child some control over the course and content of the interview. B) Teach the child about the negative consequences of an inadequate interview. C) Arrange for one of the child's parents to speak with him or her privately. D) Promise the child a reward for participating in the interview.
A
A nurse is interviewing an elderly client and begins the interview by evaluating the client's mental status. The nurse does this based on an understanding of which of the following? A) The aging brain is more easily affected by pathology. B) Older clients have decreased intellectual capacity. C) The brain is the last organ to experience an age-related decline. D) The client is always the most reliable person to provide the data.
A
A nurse is presenting a class for new parents about infant care. To decrease the risk of sudden infant death syndrome, the nurse should encourage parents to place their sleeping infants in what position? A) Prone B) Supine C) High Fowler's D) Low Fowler's
A
A pregnant client asks the clinic nurse what she can use to relieve her nasal "stuffiness." The nurse bases the answer on the most likely cause of the congestion, which is attributable to which hormone? A) Estrogen B) Progesterone C) Thyroxine D) Relaxin
A
After teaching a group of students about geriatric syndromes, the instructor determines that the teaching was successful when the students identify which of the following as an example? A) Confusion B) Pneumonia C) Heart failure D) Renal failure
A
An older adult client has received a diagnosis of stress incontinence, and the nurse is planning the client's subsequent care. What health education is most relevant to this client's needs? A) Pelvic floor strength training and activity management B) Appropriate use of incontinence pads and dietary modifications C) Management of fluid and electrolyte intake D) Aseptic technique for intermittent catheterization and fluid restriction
A
During the assessments of infants' genitalia, what finding most clearly warrants referral for further assessment? A) A newborn male has an undescended testicle. B) A newborn female has bloody vaginal discharge. C) A newborn female has engorged labia. D) A newborn male has intact foreskin.
A
The nurse has assessed the thorax and lungs of an elderly client, as well as reviewing the results of lung function testing. Which of the following findings should the nurse attribute to possible pathology rather than expected, age-related changes? A) Respiratory rate of 30 breaths per minute B) Decreased vital capacity C) Increased residual volume D) Presence of a slight barrel chest
A
The nurse is assessing a newborn's rooting reflex. What action should the nurse perform during this assessment? A) Touch the infant's lip or cheek with a gloved finger. B) Place a gloved finger in the newborn's mouth. C) Touch the ball of the newborn's foot. D) Hit the surface near where the newborn is lying.
A
The nurse is assessing an older adult client's vaccination history. This aspect of the client's history will have a significant bearing on her risk for what health problem? A) Pneumonia B) Urinary tract infections C) Cellulitis D) Tuberculosis
A
The nurse is preparing to measure the head circumference of a newborn. In a healthy newborn, the nurse should expect the circumference of the infant's head to be within what range? A) 33 to 35.5 cm B) 35 to 37.5 cm C) 37 to 39.5 cm D) 39 to 41.5 cm
A
The nurse's assessment of a child's hair reveals that it is clean and neatly trimmed but exceptionally dry and brittle. What is the nurse's best response to this finding? A) Assess the child for signs and symptoms of impaired nutrition. B) Assess the child for indications of abuse or neglect. C) Facilitate a referral to a dermatologist. D) Encourage the child's mother to ensure that the child gets adequate exposure to sunlight.
A
The nurse's inspection of a young child's anus reveals the presence of hemorrhoids. How should the nurse best interpret this assessment finding? A) Hemorrhoids are unusual in children and warrant further assessment. B) Hemorrhoids are a common indication of deficient fluid intake in children. C) Hemorrhoids are common in children until they attain bowel continence. D) Hemorrhoids in a child younger than 10 are suggestive of colorectal cancer.
A
When auscultating the heart of an elderly client, the nurse detects a soft systolic murmur at the base of the heart. The nurse understands that this is most likely the result of which of the following? A) Calcification of the aortic and mitral valves B) Accumulation of amyloid in the pacemaker cells C) Enlargement of the heart muscle D) Regurgitation through a stenotic valve
A
Which action would be most appropriate when a nurse assesses the umbilical cord of a 4-day-old infant and finds it to be dried and black? A) Notify the newborn's physician. B) Apply warm compresses. C) Apply an antibiotic ointment. D) Recognize this as normal.
A
Which technique should the nurse use to perform scoliosis screening in a school-age child? A) Have the child bend forward at the waist. B) Measure the length of each of the child's legs. C) Measure the distance between the child's knees and ankles. D) Ask the child to walk across the room.
A
The gerontologic nurse is using the SPICES screening tool to assess an older adult's health status. The nurse will assess for which of the following health problems? Select all that apply. A) Sleep disturbances B) Infection C) Poor nutrition D) Falls E) Pain
A, C, D
A home care nurse is assessing an older adult's functional status. The nurse should identify which of the following as an instrumental activity of daily living? A) Bathing B) Cooking C) Toileting D) Eating
B
A new mother asks the nurse, ìWhat are those small white spots on my baby's nose?î Which response by the nurse would be most appropriate? A) ìThose are small glands that look like whiteheads but will disappear soon.î B) ìThose white spots are lesions containing pus and are caused by a minor skin infection.î C) ìNewborns retain sweat, which causes those white bumps on their skin.î D) ìOften newborns have a rash of this type, which fades in a few days.î
B
A new mother rings her call bell after giving birth to a healthy infant 18 hours earlier. The client states that her infant ìlooks like she has milk coming out of her nipples.î How should the nurse best interpret this phenomenon? A) The infant is showing signs of postnatal mastitis. B) This is a normal finding that results from hormonal stimulation. C) This is an expected finding in female infants but an unexpected finding in male infants. D) The nurse should plan to manually express the liquid from the infant's breasts.
B
A nurse assesses a client's blood pressure and the findings suggest orthostatic hypotension. Which area should the nurse emphasize during client education? A) Daily exercise routine B) Prevention of falls C) Diet high in iron D) Vitamin supplementation
B
A nurse assesses the skin of an older adult's forearms and observes purpura. The nurse interprets this finding as indicative of which of the following? A) Elder abuse B) Vascular fragility C) Poor circulation D) Herpes zoster
B
A nurse has assessed an elderly client and is preparing to analyze the assessment data. Which of the following would the nurse need in order to accurately perform data comparison? A) Client's major complaints B) Client's usual daily patterns C) Client's adherence to treatment D) Client's underlying pathology
B
A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score? A) Temperature B) Reflex irritability C) Head circumference D) Weight
B
A nurse is using the Katz Activities of Daily Living tool to assess an older adult's functional status. What question will the nurse include in this assessment? A) ìWho generally prepares your meals and snacks?î B) ìDo you require any assistance when showering or bathing?î C) ìDo you feel like you have enough support from your family?î D) ìAre you able to shop for your own groceries?î
B
A preadolescent girl comes to the clinic for a sports physical exam. The nurse notes beginning breast development and documents which of the following? A) Gynecomastia B) Thelarche C) Menarche D) Adolescence
B
A school nurse plans to test hearing acuity in students who range between kindergarten and sixth grade. Which of the following would be most appropriate method? A) Loud noise screening B) Audiometry C) Whisper test D) Weber test
B
After inspecting an adolescent male's genitalia, the nurse documents the findings as Tanner stage 3. Which of the following findings would be most likely? A) Scrotum and testes slightly enlarged; sparse, long, downy pubic hair B) Penis elongated; pubic hair sparse over pubis, coarse and curly C) Penis increased in width; abundant pubic hair not extending to thighs D) Penis of adult size; dark curly abundant pubic hair to thighs
B
An elderly client with a history of sinusitis has been taking antibiotics for this condition. The nurse should assess for what potential adverse effect of treatment? A) Exacerbation of cardiac dysrhythmias B) Candidal infection C) Overdrying of nasal passages D) Exacerbation of hypertension
B
An older adult client has been admitted for assessment related to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive changes? A) The client has a family history of cognitive disorders. B) The client recently began a new medication regimen. C) The client has been under significant psychosocial stress. D) The client's cognition has declined over several months.
B
An older adult client has been admitted to the intensive care unit after experiencing a serious decline in health due to influenza. The client's family is surprised that influenza could have such serious health consequences. When educating the family about this phenomenon, what should the nurse describe? A) Older adults' immune systems cannot produce new antibodies. B) Older adults have a diminished physiologic reserve. C) Older adults lack resistance to many common viruses. D) Older adults cannot tolerate antibiotics used to treat influenza.
B
The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would indicate to the nurse that his rate is within the age-appropriate range for this child? A) 16 breaths/minute B) 24 breaths/minute C) 32 breaths/minute D) 40 breaths/minute
B
The nurse has assessed the head circumference (HC) of an 18-month-old during a regular checkup. The nurse should compare the percentile of the child's HC to which of the following? A) The child's body mass index B) The child's height and weight percentiles C) The child's chest circumference percentile D) The child's developmental stage
B
The nurse is assessing a 6-year-old child. While auscultating the child's apical heart rate, the nurse notes that the child's heart rate increases during inspiration. What is the nurse's most appropriate action? A) Arrange for a STAT electrocardiogram. B) Document this as an expected assessment finding. C) Facilitate a referral for medical assessment. D) Reposition the child and then reassess.
B
The nurse is assessing an elderly client who is receiving tube feedings via a nasogastric tube. The nurse should assess the client for signs and symptoms of which of the following? A) Gingivitis B) Sinusitis C) Epiglottitis D) Cellulitis
B
The nurse is assessing the skin of a 12-hour-old infant. Which assessment finding would be cause for concern? A) Milia B) Jaundice C) Erythema toxicum D) Mongolian spot
B
The nurse is completing a head-to-toe assessment of a newborn infant. How should the nurse determine if the infant's anus is patent? A) Spread the infant's buttocks to facilitate inspection. B) Observe for the passage of meconium. C) Insert a gloved finger 0.5 to 1 cm into the rectum. D) Auscultate for bowel sounds to all four abdominal quadrants.
B
When assessing a newborn, the nurse observes that the infant's hands and feet are bluish in color. The nurse interprets this finding as being suggestive of which of the following? A) Cardiopulmonary dysfunction B) Peripheral vascular disease C) Acidñbase imbalance D) Ineffective temperature regulation
B
When assessing adolescent girls, the nurse should know that which of the following usually appears first? A) Pubic hair B) Breast buds C) Axillary hair D) Menses onset
B
When examining the skin of an elderly client, the presence of which skin lesions should indicate a need for referral? A) Cherry angioma B) Actinic keratosis C) Seborrheic keratosis D) Acrochordons
B
When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen. Which of the following would be most appropriate for the nurse to do? A) Omit the entire abdominal exam. B) Palpate with the child's hand under the nurse's hand. C) Ask the parent to discipline the child. D) Explain the purpose of the exam to the child.
B
Which child should the pediatric nurse suspect of having a developmental delay? A) A 5-month-old who does not sit unsupported B) An 11-month-old who does not pull himself to a standing position C) A 3-month-old who cannot grasp an object voluntarily D) A 12-month-old who cannot build a tower of eight blocks
B
A nurse is assessing a 9-month-old infant. Which reflexes would the nurse expect to assess? Select all that apply. A) Rooting B) Sucking C) Tonic neck D) Moro E) Palmar grasp F) Babinski
B,F
A client at 22 weeks' gestation comes to the clinic complaining of earache and decreased hearing. Otoscopic examination of the ear is normal. The nurse explains to the client that her symptoms are pregnancy-induced as a result of what physiologic change? A) Thickened, dry cerumen B) Infection of the inner ear C) Vascularity of the eardrum D) Auditory nerve compression
C
A client at 32 weeks' gestation has been placed on complete bed rest due to premature labor contractions. The nurse should prioritize assessments for which of the following complications? A) Hyperglycemia B) Urinary tract infection C) Thrombophlebitis D) Leg cramps
C
A clinic nurse is assessing a 6-month-old infant prior to the administration of scheduled immunizations. The nurse should anticipate that the infant's resting heart rate will be nearest to what value? A) 80 beats per minute B) 100 beats per minute C) 120 beats per minute D) 140 beats per minute
C
A mother voices concern about the amount of time her school-age child sleeps. When responding to the mother, the nurse understands that this age group sleeps an average of how many hours each night? A) 11 to 12 B) 9 to 10 C) 8 to 9.5 D) 7 to 8
C
A newly pregnant client says that she has heard that her nipples will leak milk during the pregnancy. The nurse should tell the client that she should expect to be able to express colostrum from her nipples beginning at how many weeks' gestation? A) 6 to 8 B) 12 to 14 C) 24 to 28 D) 34 to 36
C
A nurse assesses the pulses of an infant and notes that the femoral pulses are weak. Which of the following health problems should the nurse suspect? A) Right ventricular enlargement B) Sinus arrhythmia C) Coarctation of the aorta D) Patent ductus arteriosus
C
A nurse has completed an assessment of a school-age child. The nurse has identified several ìsoft signsî of potential neurologic impairment. How should the nurse best interpret these findings? A) Recognize that the findings are related to developmental tasks rather than neurologic pathology B) Recognize the need for an emergency neurological assessment C) Recognize that the findings may or may not indicate the presence of a neurologic problem D) Recognize that the findings need to be interpreting in light of the child's education level
C
A nurse is preparing a health education class for a group of older adult clients at a local senior center. The nurse is focusing on health promotion and disease prevention. Which condition would the nurse cite as a common cause of infection-related deaths in the elderly? A) Pyelonephritis B) Cellulitis C) Pneumonia D) Meningitis
C
A nurse is providing an in-service presentation to a group of new pediatric nurses and reviewing differences in assessment of children and adults. When describing the heart sound typically auscultated in children in comparison to an adult, which characteristic would the nurse describe? A) Children typically have softer heart sounds. B) Children typically have less harsh heart sounds. C) Children typically have higher pitched heart sounds. D) Children typically have heart sounds of longer duration.
C
An elderly client's history reveals the use of antihistamines. When inspecting the client's mouth, which of the following would the nurse expect to find? A) Resorption of the gum ridge B) Swollen, red tongue C) Decreased saliva production D) Pocketing of food
C
An older adult client who enjoys good overall health has sought care because of a recent onset of weakness and fatigue. The client is unaware of any precipitating events. How should the nurse proceed with assessment? A) Perform a focused respiratory assessment. B) Obtain the client's vaccination history. C) Assess the client for signs and symptoms of anemia. D) Assess the client for evidence of chronic heart failure.
C
During an assessment of an elderly client, the nurse notes a decrease in pupil size and a slowed reaction of the pupil to light. Accommodation and convergence are normal. Based on these findings, which of the following should the nurse emphasize with client education? A) Use drops to prevent dryness B) Wear sunglasses outdoors C) Avoid driving at night D) Obtain an eye examination
C
In preparation for discharge, the nurse is assessing a newborn infant's hearing acuity. How should the nurse best perform this assessment? A) Determine whether the infant turns his or her head toward verbal stimuli. B) Determine whether the infant makes eye contact in response to a loud voice. C) Determine whether a loud noise near the infant evokes a startle response. D) Determine whether the infant appears to recognize the mother's voice.
C
The advanced practice nurse is preparing to perform a pelvic examination on an elderly female client. Which of the following would the nurse expect to find? A) Elongation of the vagina B) Thick, pale epithelium C) Decreased vaginal secretions D) Palpable ovaries
C
The children of an elderly client tell the nurse, ìHe has lost his appetite. He eats very small amounts, and only twice a day.î Which suggestion would be most appropriate? A) Inform them that he will eat when he is hungry. B) Counsel them to weigh him daily. C) Recommend nutrient-dense foods. D) Advise them to restrict fluid intake.
C
The nurse assesses the uterine fundus and finds it to be halfway between the symphysis pubis and the umbilicus. The nurse knows that this is an expected finding at how many gestational weeks? A) 6 B) 12 C) 16 D) 20
C
The nurse completes the initial newborn assessment and notes the presence of fine, downy hair on the infant's shoulders and back. The nurse documents the presence of which of the following? A) Vernix B) Milia C) Lanugo D) Nevi
C
The nurse has identified a need to discuss sexuality with a 15-year-old client. How should the nurse best plan this aspect of the health interview? A) Obtain informed consent for the health interview. B) Begin by explaining appropriate and acceptable sexual behavior. C) Discuss the matter when a parent is not present. D) Ensure that a chaperone is in the room during the interview.
C
The nurse inspects a 10-day-old infant's umbilicus and notes that it is reddened with the presence of slight discharge. What nursing diagnosis is suggested by these data? A) Risk for contamination B) Ineffective peripheral tissue perfusion C) Infection D) Risk for injury
C
The nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea (runny nose). When analyzing these data, the nurse should consider which of the following? A) Nasal congestion in an infant is indicative of infection. B) Nasal mucus in infants should be treated with an inhaled vasoconstrictor. C) Nasal congestion can impair oxygenation because infants are nose breathers. D) Nasal congestion in infants is an expected finding for the first 6 weeks of life.
C
The nurse is auscultating the bowels of an infant who was born 10 hours ago. What principle should guide the nurse's assessment and data analysis? A) Bowel sounds are not normally audible until 48 to 72 hours postpartum. B) Bowel sounds are not normally audible until 24 to 48 hours postpartum. C) Bowel sounds should be audible every 10 to 30 seconds. D) Bowel sounds should be absent at rest and audible after palpation.
C
The nurse is completing a head-to-toe assessment of a pregnant client. What anatomic area should be examined when assessing the Montgomery tubercles? A) Thorax B) Abdomen C) Breasts D) Perineum
C
The nurse is interviewing an 82-year-old client who is accompanied by her daughter. The daughter states that her mother is ìunable to hold her urine,î and the client attests that this is true. What question should the nurse prioritize when assessing the client's urinary incontinence? A) ìDid you deliver your children vaginally or by cesarean section?î B) ìHave you been prone to urinary tract infections in the past?î C) ìIs this something that has begun to happen just recently?î D) ìHave you noticed any change in your bowel function?î
C
The nurse is performing Ortolani's maneuver to test for congenital hip dysplasia in a newborn infant. What finding would suggest the presence of hip dysplasia? A) The infant expresses no signs of pain or discomfort during manipulation of the hip. B) The nurse is unable to perform passive range of motion of the infant's hip joint. C) The nurse hears a click from the site of the infant's hip joint. D) The nurse is unable to bring the infant's knees into alignment.
C
The nurse is preparing to measure the chest circumference of a 2-day-old newborn. The nurse would place the tape measure at which area? A) High up under the axillary area B) At the level of the umbilicus C) At the level of the nipple line D) Midway between the nipple line and umbilicus
C
The nurse is teaching a group of parents of children of various ages how to best measure a child's temperature. The nurse instructs the parents that rectal temperature measurement is indicated in which situation? A) During the newborn period B) When a child is dehydrated C) When no other route is feasible D) When rapid temperature changes occur
C
The pediatric nurse is obtaining the nursing history of a 4-year-old girl who is accompanied by her mother. What question should the nurse pose to the child's mother? A) ìIs your daughter able to pick out her name from a page of writing?î B) ìDo you think your daughter can see others' points of view?î C) ìDoes your daughter often ask 'why'?î D) ìDoes your daughter like to collect things?î
C
The pregnant client tells the nurse she has a history of mitral valve stenosis as a sequela of rheumatic fever. The nurse plans to closely monitor the client based on the understanding that which physiologic change in pregnancy increases this client's risk for complications? A) Physiologic anemia B) Altered carbohydrate metabolism C) Increased blood volume D) Hormonal changes
C
When describing cultural differences related to tooth eruption, the nurse explains that permanent teeth typically appear earlier in which group? A) Caucasians B) Hispanics C) African Americans D) Native Americans
C
While assessing an infant's abdomen, which finding would the nurse interpret as necessitating immediate evaluation and treatment? A) Palpable mass B) Tenderness C) Rigidity D) Gurgling sounds
C
A client at 34 weeks' gestation is lying on an examination table while the nurse asks questions. The client says she is feeling dizzy. What intervention by the nurse would be most appropriate? A) Measure orthostatic blood pressures. B) Have her get up and walk around. C) Provide her with a glass of juice. D) Turn her on her left side.
D
A client's medical assessment reveals no heart disease. An electrocardiogram is performed and a dysrhythmia is noted. The nurse interprets this finding as most likely reflecting which of the following age-related changes? A) Decreased ventricular compliance B) Peripheral vascular disease C) Widening pulse pressure D) Collagen deposits around pacemaker cells
D
A nurse is conducting a workshop with a group of adults who are enrolled in a parenting class. Which of the following would the nurse emphasize as important in helping the school-age child achieve the psychosocial task of industry and avoid inferiority? A) Allow independence B) Encourage competition C) Increase socialization D) Acknowledge accomplishments
D
A parent of an ill infant states, ìWe've gave him ibuprofen for a fever, and he had an allergic reaction.î Which response would be most appropriate? A) ìIs he allergic to any other drugs?î B) ìI will write that on his chart so he won't be given any.î C) ìHow often has he received ibuprofen?î D) ìDescribe what happens to him when he takes ibuprofen.î
D
An older adult client has come to the clinic with new complaints of fatigue, constipation, and cold intolerance. This client may benefit from referral for which of the following purposes? A) Liver function testing B) Cognitive testing C) Lung function testing D) Assessment of thyroid function
D
During a well-child visit, a parent asks the nurse the best way to manage negativism in her toddler. Which suggestions by the nurse would be most appropriate? A) Implement punishment appropriate for the child's age. B) Spend more quality time with the child. C) Repeatedly tell the child not to always say ìno.î D) Reduce the opportunities for a ìnoî answer.
D
During palpation of a young child's abdomen, the nurse assesses the liver. Which of the following would the nurse expect to find? A) The liver can be palpated 4 cm below the right costal margin. B) The liver is not palpable. C) The liver is found at the left costal margin. D) The liver is located 2 cm below the right costal margin.
D
During the health history, a nurse asks a mother to describe the play activities of her school-age son. The mother reports activities that are typical for this age group. The nurse would document this as which type of play? A) Imitative B) Associative C) Parallel D) Competitive
D
The nurse assesses the respirations of a 2-week-old infant and identifies periods of apnea lasting longer than 20 seconds. What should the nurse do next? A) Assess the apical heart rate. B) Percuss the lungs for consolidation. C) Auscultate the lungs for adventitious sounds. D) Inspect the shape of the thorax.
D
The nurse is assessing a 2-day-old infant prior to discharge home from the hospital with his mother. When assessing the infant's eyes, what finding would the nurse consider to be abnormal? A) The infant is unable to follow a moving object or light. B) The infant's periorbital area is slightly edematous. C) The infant's pupils react to light. D) The infant's sclerae have a yellowish tint.
D
The nurse is assessing a newborn's neuromuscular maturity in light of the infant's known gestational age. Which of the following would the nurse expect to find if the newborn was premature? A) Flexed arms and legs B) Elbow position less than midline C) Heel distant from ear D) Delayed arm recoil
D
The nurse is assessing the anterior fontanelle of a 4-month-old infant brought to the clinic for a well-child exam. Which of the following would the nurse expect to assess? A) Sunken fontanelles B) Closed fontanelles C) Bulging fontanelles D) Flat fontanelles
D
The nurse is conducting a functional assessment of an older adult client. The nurse should focus questions on which area? A) Feelings about aging B) Quality of life C) Recent personal losses D) Activities of daily living
D
The nurse is experiencing challenges in eliciting information during the health interview of a 4-year-old boy. How can the nurse best foster communication with the child? A) Set a time limit for completing the interview. B) Ask the child to talk about himself in the third person. C) Explain the purpose of the interview in simple terms. D) Engage the child in play.
D
The nurse is meeting the parents of an ill child for the first time and is preparing to perform the health interview. In addition to gathering health data, what additional goal should the nurse prioritize during this interaction? A) Gauge the parents' own levels of health. B) Emphasize the importance of adherence to treatment. C) Identify the family's socioeconomic status. D) Foster trust with the child's parents.
D
The nurse is participating in a vision-screening program for children age 3 to 10 years. The nurse would expect a child to have 20/20 vision at what age? A) 3 to 4 B) 4 to 5 C) 5 to 6 D) 6 to 7
D
The nurse is performing an otoscopic examination of an infant's ears. Which of the following actions should the nurse do? A) Pull the pinna forward and down. B) Pull the pinna up and back. C) Pull the pinna straight back. D) Pull the pinna down and back.
D
The nurse is reviewing an older adult's recent laboratory values prior to performing a physical assessment. What value would most clearly indicate the need for further nutritional assessment? A) Hemoglobin 12.2 g/dL B) Hematocrit 40% C) Serum albumin 3.9 g/dL D) Vitamin B12 91 μg/ml
D
The nurse's assessment of an infant reveals a positive Barlow's sign. What collaborative problem should the nurse consequently identify? A) RC: Failure to thrive B) RC: Jaundice C) RC: Patent ductus arteriosus D) RC: Hip displacement
D
The school nurse is assessing a 15-year-old client. The nurse should understand that this child's current priorities will most likely reflect what developmental task? A) Exerting influence B) Learning new information C) Becoming productive D) Developing a personal identity
D
When assessing an elderly client's hip joint after a fall, which of the following should lead the nurse to suspect that the client has a hip fracture? A) Internal rotation of the affected leg B) Abduction of the affected leg C) Partial weight bearing D) Thigh pain
D
When examining the eyes of an elderly client, the nurse observes a brownish discoloration of the lens. The nurse interprets this finding as being suggestive of what health problem? A) Conjunctivitis B) Presbyopia C) Glaucoma D) Cataracts
D
When the nurse palpates the neck of an infant, he notes the presence of crepitus at the right shoulder area. The infant also exhibits decreased movement in the right arm. Which of the following should the nurse suspect? A) Osteomyelitis B) Down syndrome C) Fractured humerus D) Fractured clavicle
D
Which finding would require further evaluation or referral when auscultating heart sounds on an 8-year-old client during a routine physical exam? A) Audible S3 B) Soft systolic murmur C) Sinus arrhythmia D) Pulse rate 120 beats per minute
D
