Care Across the Lifespan - PrepU

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?

Document this finding as on the high end of the normal range and plan to reassess.

Changes that are found during the mental status examination of a client diagnosed with delirium include what?

Difficulty focusing

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.

"Let's see about further developmental testing."

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique is most helpful?

Ask the child to draw a picture.

The nurse is assessing a newborn (view the figure). What should the nurse expect the infant to do?

Close the fingers around the nurse's hands. (Explanation: The nurse is assessing the newborn's grasp reflex. If the reflex is present, the newborn will close the fingers around the nurse's hands. Placing the nurse's fingers in the newborn's hands will not cause the infant to turn the head or extend the arms. The newborn does not have sufficient muscle control to lift the torso.)

A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform?

Create a calming environment with little stimuli. (Explanation: Bathing sometimes increases stimulation in clients who are confused or have dementia. Reducing the stimuli and providing a calm environment will decrease agitation. Turning down the lights, ensuring the adequacy of the environment where the client is being bathed and playing soft, relaxing music are possible interventions to calm the client. Nurses are responsible for the care of their clients and the staff that care for them. Delegating care of a client with dementia may require special instructions for the UAP.)

What term is used to describe various disorders that progressively affect cognitive function?

Dementia

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. What scale should the nurse use while assessing pain in this infant?

FLACC SCALE

When completing an assessment of a healthy adolescent client, which measure would be most appropriate?

Gather information from the parents and adolescent; then assess the adolescent in private. (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.)

An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination?

Have a female health care worker present.

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?

Keeping a journal and scrapbook.

Nursing staff are trying to provide for the safety of an older adult with moderate dementia. The client is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. Which action by the nurse is most appropriate?

Move the client to a room near the nurse's station and install a bed alarm.

A nurse records a pulse rate of 170 beats/minute on a patient's flow chart. For which of the following age groups would this be considered a normal reading?

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, and an adult is 60 to 100.)

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?

Perform the blood pressure measurement last. (Explanation: 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.)

A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this client's care plan to prevent injury?

Remove hazards from the environment.

Which would be the priority goal for a client with dementia?

Safety (Explanation: Although nutrition, physical stability, and sleep are important, safety is the priority, especially as the dementia progresses.)

A school nurse is developing a program about positive health practices for adolescents. The nurse includes information about

Self-esteem (Explanation: Programs to promote good health habits for adolescents include issues about self-esteem. Programs relating to blood pressure control, chronic diseases, and prenatal health are more appropriate for other age groups.)

A toddler's mother exits the room to talk to the physician in the hallway. The nurse caring for the toddler notes that the child starts to cry when he no longer sees his mother in the room. He soon stops crying and appears saddened and depressed. The nurse recognizes this behavior as which of the following?

Separation anxiety

Which situation would lead the client's family to suspect onset of dementia?

The client has increasingly experienced disorientation to familiar surroundings. (Explanation: Dementia is a progressive cognitive disorder in older adults, characterized by increased forgetfulness, impaired judgment, progressive confusion, and disorientation. Other reasons may exist for the client not reporting a broken air-conditioner (e.g., financial) or not attending church (e.g., time or transportation). So these situations may not necessarily be related to dementia. Confusion, or delirium, can be an adverse effect of medications. This condition is temporary and can be resolved by stopping the use of the medication.)

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?

The newborn can suck, swallow, sneeze, and yawn (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.)

The emergency department nurse is caring for a 2-month-old infant who was brought in by a hired caregiver. The infant is underweight and looks uncared for. The caregiver reports that the mother of the infant is unreliable and may be using drugs; the infant is often unclean and hungry when dropped off at the caregiver's home. The infant has diaper rash and a weak cry. If this situation is not remedied, what will this infant have difficulty achieving, according to Erikson's developmental theory?

Trust (Explanation: The infant learns to rely on caregivers to meet basic needs of warmth, food, and comfort. This is how the infant learns to form trust in others. Mistrust is the result of inconsistent, inadequate, or unsafe care. The other choices are later stages of Erikson's developmental theory.)

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 normal pattern in infants of this age

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:

encouraging peer visitation.

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

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.)