Fundamentals

A nurse teaches the parents of a 1-year-old infant that the primary developmental milestone to be accomplished between 12 and 15 months of age is which ability? A.Walk erect B. Climb stairs C. Use a spoon D. Say simple words

A. Walk erect Walking is the primary developmental milestone for this age group; 1-year-olds are capable of the balance and agility required for walking. A child learns to climb stairs around 15 to 18 months of age. The ability to use a spoon is not developed until 18 months of age. Speaking is not the priority at this age.

A registered nurse is teaching a nursing student about the third heart sound (S 3). Which statement given by the nursing student indicates a need for further education? A."S 3 is heard in clients with heart failure." B."S 3 is normal in pregnant women." C."S 3 is abnormal in adults over 31 years of age." D."S 3 is normal in children and young adults."

b. S3 is normal in pregnant women

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema? A.Shift of fluid into the interstitial spaces B.Weakening of the cell wall C.Increased intravascular compliance D.Increased intracellular fluid volume

A. Shift of Fluid into interstitial spaces When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces.

What should the nurse do when implementing a tertiary preventive program for cognitively impaired individuals? A. Teach children how to feed themselves. B. Encourage the use of birth control by women. C. Refer children for evaluation if they fail to meet developmental milestones. D. Use the Denver Developmental Screening Test to evaluate children attending well-child clinics.

A. Teach children how to feed themselves. Tertiary prevention is focused on interventions that prevent complete disability or reduce the severity of a disorder or its associated disabilities.

A staff member tells a nurse that an older client becomes irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response? A. Decreased ability to cope B.Loss of ability to cooperate C.Ambivalence toward authority D. Difficulty performing step procedures

A. Decreased ability to cope

The nurse is teaching expectant parents about infant development. Which parental statements indicate the need for further education? (select all that apply) A."My baby will enjoy sucking on a pacifier." B. "Toilet training is an expectation during infancy." C. "A chronic illness shouldn't impact my baby's development." D. "My baby will begin to realize that he or she is separate from me early in infancy." E. "If my wife experiences postpartum depression this could impact my baby's development."

B. "Toilet training is an expectation during infancy." C. "A chronic illness shouldn't impact my baby's development." D. "My baby will begin to realize that he or she is separate from me early in infancy."

How does the nurse identify an illness as chronic?(Select all that apply) A.The illness is reversible and often severe. B. The illness persists for longer than six months. C. The client may develop life threatening relapse. D. The symptoms are intense and appear abruptly. E. The illness affects the functioning of one or more systems.

B. The illness persists for longer than six months. C. The client may develop life threatening relapse. E. The illness affects the functioning of one or more systems. A chronic illness usually lasts longer than six months. The client with chronic illness often fluctuates between maximal functioning and serious health relapses that may be life threatening. The illness affects the functioning of one or more systems. A chronic illness is irreversible, whereas an acute illness is reversible and often much more severe than a chronic illness. The client with acute illness develops intense symptoms that appear abruptly and often subside after a relatively short period.

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? (Select all that apply) A.Heart B.Vagina C.Rectum D.Female genitalia E.Musculoskeletal system

B. Vagina C. Rectum Lithotomy to check female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system.

While teaching parents about the developmental milestones of a 15-month-old child, the nurse informs the parents about various activities that their child should be able to do. Which statement of the parent indicates effective learning? A. "My child can jump with both feet." B."My child can walk up stairs with one hand held." C."My child can creep up stairs and kneel without support." D. "My child goes up and down stairs alone with two feet on each step."

C."My child can creep up stairs and kneel without support." A 15-month-old child has the ability to creep up stairs and kneel without support because of the development of gross motor skills. The child starts jumping with both feet at the age of 30 months. The child will start walking up stairs with one hand held at the age of 18 months. The calf muscles develop sufficiently for the child to walk up and down stairs alone at the age of 24 months.

Which positioning should be avoided while assessing a client with a history of asthma? A.Sitting B.Supine C.Dorsal recumbent D.Lateral recumbent

D. Lateral Recumbent

Why does the nurse establish "moderately hard" patient-centered goals? (Select all that apply) A.To decrease the cost of treatment during therapy B.To decrease the number of follow-up visits by the patient C.To achieve the goal in a shorter period of time with less effort D.To prevent the patient from quitting before the goal is achieved E.To prevent the patient from losing motivation toward achieving the goal

D.To prevent the patient from quitting before the goal is achieved E.To prevent the patient from losing motivation toward achieving the goal Healthcare providers generally design moderately hard patient-centered goals because, if the goals are too hard to achieve, the patient may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls what expected sensory losses associated with aging? (Select all that apply) A.Difficulty in swallowing B.Diminished sensation of pain C.Heightened response to stimuli D.Impaired hearing of high frequency sounds E. Increased ability to tolerate environmental heat

B.Diminished sensation of pain D.Impaired hearing of high frequency sounds Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client? A.Spoon-shaped nails B.Transverse depressions in nails C.Softening of nail beds and flat nails D.Red or brown linear streaks in nail bed

C.Softening of nail beds and flat nails Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base and is seen in conditions of oxygen deficiency, such as in heart or pulmonary diseases. Conditions such as iron deficiency anemia and syphilis cause curvature of nails, which is called koilonychia. Transverse depressions in nails indicate a temporary disturbance of nail growth called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis. They are called splinter hemorrhages.