Development-Pam

1. A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages? A. 3 years B. 4 years C. 5 years D. 6 years

A

11. A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute. B. Assess the apical pulse with a Doppler device. C. Assess the pedal pulses for a full minute. D. Assess the pedal pulses with a Doppler device.

A

8. A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.) A. Amenorrhea B. Verbalized desire to gain weight C. Altered body image D. Hyperactivity E. Bradycardia

A,C,D,E

19. A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select all that apply.) A. Transverse palmar creases B. Large ears C. Muscular hypertonicity D. Protruding tongue E. Low birth weight

A,D

13. A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. 3 months B. 6 months C. 9 months D. 12 months

B

14. A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? A. Blood in the IV tubing B. Absence of blanching at the insertion site C. Edema in the palm of the hand D. Warmth around the insertion site

C

16. A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. Fatigue B. Hypertension C. Bradycardia D. Diarrhea

A

21.The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A. Evaluate chest expansion. B. Check pupillary response to light. C. Assess the capillary refill. D. Check client's response to questions about place and time.

A

28. A nurse is assessing a lesion on a client who has basal cell carcinoma. The nurse should expect which of the following findings? A. A pearly, shiny nodule B. A pigmented papule C. A rough, scaly tumor D. A weeping vesicle

A

6. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support

A

7. A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A. Protein B. Calcium C. Vitamin B1 D. Vitamin D

A

5. A nurse is completing an assessment of a 1-month-old newborn. Which of the following developmental skills is an expected finding? A. Displays a social smile B. Follows movements of objects with eyes C. Reacts to sounds by turning head D. Makes babbling sounds

B

9. A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first? A. Client's history of previous accidents B. Date of the client's last tetanus immunization C. Client's blood alcohol level D. Signs of wound infection

B

18. A nurse is collecting data from an adolescent. Which of the following should the nurse identify as the greatest risk for suicide? A. Availability of firearms B. Family conflict C. Homosexuality D. Active psychiatric disorder

D

4. A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect? A. Absent plantar reflexes B. Lengthened thigh on the affected side C. Inwardly turned foot on the affected side D. Asymmetric thigh folds

D

29. A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect? A. Weight loss B. Increased urine output C. Bradycardia D. Orthopnea

D

24. A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? A. Chvostek's sign B. Cullen's sign C. Chadwick's sign D. Goodell's sign

B

25. A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider? A. Splinter hemorrhages to the nails B. Dyspnea C. Fever D. Clusters of petechiae in the mouth

B

3. A nurse in a provider's office is collecting a health history from a client who is at risk for primary osteoporosis. Which of the following findings is a risk factor for the development of osteoporosis? A. Obesity B. Sedentary lifestyle C. Long-term use of diuretics D. Prolonged stress

B

10. A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.) A. Bradycardia B. An increase in neutrophils C. An increase in RBCs D. An increase in platelets E. Localized edema

B,E

17. A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension

C

22. A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Oliguria D. Bradypnea

C

23. A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? A. Low body temperature B. Jugular vein distention C. Skin tenting present D. Blood pressure 178/90 mm Hg

C

26. A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Hyperactive reflexes B. Extreme thirst C. Weak, irregular pulse D. Hyperactive bowel sounds

C

27. A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses? A. Radial B. Popliteal C. Carotid D. Apical

C

2. A nurse in an urgent care clinic is studying the developmental stages of various clients. In which of the following clients should the nurse expect to see manifestations of autism? A. Neonate B. Toddler C. Middle age D. Geriatric

B

20. A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection? A. Oliguria B. Bulging fontanel C. Negative Brudzinski sign D. Jaundice

B

. A nurse in a community health clinic is administering seasonal inactive influenza vaccine. Before administering it, the nurse must confirm that the client is not allergic to which of the following? A. Shellfish B. Eggs C. Gelatin D. Yeast

B

12. A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? A. After palpating the abdomen B. Prior to percussing the abdomen C. After assessing for kidney tenderness D. Prior to inspecting the abdomen

B

15. A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate? A. Observe for the presence of Kernig's sign. B. Perform a Romberg's test. C. Check the function of cranial nerve V. D. Inspect for the presence of clubbing.

B