ADN 140 Care Accross the Lifespan

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.

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

Demetia

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.

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.

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep.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.

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

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.

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

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

Self-esteem

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.

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

Close the fingers around the nurse's hands.

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

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

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