Ch 18-21 N303
Which statement reflects an expected developmental task of a 40-year-old man?
"My wife and I have divided the chores with the children since we're both working."
A 15-year-old boy approaches the school nurse and describes how uncomfortable he is around the girls because most of them are taller than he is. What is the nurse's best response to this adolescent?
"The growth spurt during adolescence occurs in girls 18-24 months before it occurs in boys."
The nurse is assessing an infant. The nurse takes a toy and moves it from the infant's sight. The nurse is assessing for which of the following?
Object permanence
The nurse is assessing a 1-year-old and suspects respiratory distress. Which finding indicates this?
Observation of sternal and supraclavicular retractions with breathing
During an initial prenatal visit the nurse identifies which factor as consistent with a high-risk pregnancy?
Patient smokes one-half pack of cigarettes a day.
A patient with a missed menstrual period and nausea has which sings and symptoms of pregnancy?
Presumptive
The nurse is assessing an older patient's ability to perform IADLs. What is included in this assessment?
Proper use of medications Cooking dinner Using public transportation Writing checks
The nurse notes that a child is having a great deal of difficulty adjusting to the new school year. According to Erickson's theory, personality development depends on:
resolving conflict successfully within each stage
The nurse is assessing a newborn and notices the child has a cleft palate. What are the risks associated with this finding?
speech impairments Hearing impairment Failure to thrive Premature birth
The nurse is palpating the fundal height of a pregnant patient. The nurse knows that to determine fundal height, one needs to measure from the__ to the top of the fundus.
symphysis pubis
The nurse is assessing a patient in the 8 month of pregnancy. The nurse would expect to find:
the position of the heart changes slightly.
The nurse is performing an eye exam on a child. The nurse knows that the child will have the visual acuity of an adult at which age?
6 years
The nurse notes which finding as abnormal during a thoracic assessment of an older adult?
Bronchovesicular breath sounds in the peripheral lung fields
The nurse is assessing a 72-year-old patient in the clinic. Which statement made by a 72-year-old patient describes a normal process of aging?
"Food does not taste the same as it used to."
The mother of a child tells the nurse that she is concerned that her child may be having trouble hearing. Which statement made by a parent suggests a possible hearing impairment in the child?
"My 4-month-old baby does not respond to loud noise."
A nurse is assessing an infant who is able to pull up to a sitting position, turn from prone to side position, laugh and babble, and show interest in her surroundings. These behaviors are consistent with an infant of which age?
3 months old
What would be an abnormal finding for a 7-year-old African American boy?
Abdominal distention
During inspection of the mouth of a 72-year-old male patient, the nurse notices a red lesion at the base of his tongue. What additional information does the nurse obtain from this patient?
Alcohol and tobacco use
Which are expected findings of a newborn's respiratory assessment?
Bronchovesicular breath sounds in the peripheral lung fields.
On inspection of the eye of a 82-year-old woman, the nurse notes which finding as abnormal?
Clear cornea with a gray-white ring around the limbus
The nurse is performing an assessment on an older patient. Which change that occurs with aging explains why an older adult may be unaware of an infection or injury to the eye?
Decreased corneal sensitivity
In assessing the mood of older adult patients, a nurse documents which finding as abnormal?
Depression that interferes with the ability to perform activities of daily living
A school nurse is developing a health seminar for the tenth grade student assembly. When planning learning activities, the nurse should consider which developmental task of the adolescent population?
Developing mature peer relationships and accepting physical changes
A pregnant patient in her first trimester is complaining of nausea. The patient asks why she feels so sick. The nurse explains that anorexia and nausea are common to the first trimester of pregnancy because of which of the following?
Elevated levels of human chorionic gonadotropin
While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason?
Enhances visualization of the tympanic membrane by straightening the ear canal.
Which finding of a preschooler during a cardiovascular system examination is abnormal?
Failure to gain weight because of fatigue while eating
Which concepts are included in the developmental assessment of a family?
Families undergo change as family members age. There are multiple and complex interrelationships within some families. Individuals often struggle with being members of more than one family.
Which finding is expected when assessing an 11-year-old child?
Five pound weight gain and beginning of growth spurt
The nurse suspects that a child has sensory impairment. At what age can the child undergo sensory neurologic testing?
Kindergarten age
The nurse notes that a 2-year-old child has a cough that sounds like a bark. What other findings should the nurse anticipate?
Labored breathing and fever
Which finding is an expected age-related change for a woman 80 years old?
Loss of height
The nurse is assessing a 13-month-old. The nurse notes which reflexes as normal for this age group?
The infant's toes fan when the lateral surface of the sole is stroked.
A woman in her seventh month of pregnancy reports that her gums bleed easily. What is the significance of this data?
This is a common finding and is caused by increased vascularity and proliferation of the gums.
A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding?
This is a normal finding at this age.
The nurse assesses that a woman in her eighth month of pregnancy has a wide thoracic cage. What best explains this finding?
This is considered a normal finding with advanced pregnancy.
The nurse is performing a developmental assessment on a child in the outpatient setting. The primary purpose focus of this assessment will be to:
identify children below the normal developmental level for their age group.
The nurse has completed a well visit for a 65-year-old patient. Which immunization would be recommended for this patient?
influenza annually
The nurse is assessing a 72-year-old patient who was diagnosed with osteoporosis at age 65. The nurse detects the patient has kyphosis on exam. The nurse suspects:
kyphosis is a normal finding for this age group because of osteoporosis.
The student nurse is studying the difference between middle-age adults and older adults. The student nurse should be aware that the neurologic responses of older adults:
may be slower than those of younger adults.
The nurse is assessing a 5-month-old infant to determine if the infant is meeting typical milestones. Which observation should be considered an expected finding for a 5-month-old infant?
rolls over independently
The nurse is caring for an 85-year-old patient. A developmental task for this age group is:
combining new dependency needs with a continued need for independence.
The school nurse is performing a hearing screening for an adolescent. The primary focus of a history and examination for this age group would be:
explore exposure to loud noises, including music. perform the whisper test. perform screening tests for hearing loss. ask about previous antibiotic use.
What does the nurse assess for during each prenatal visit?
Blood pressure
The nurse is developing a teaching plan for a pregnant patient. One of the interventions in the plan of care is to wear sunscreen and avoid the sun. What is the rationale for the recommendation?
Pigmentation of the skin increases.
Which would be an abnormal finding during an abdominal examination of an older adult?
Report of incontinence when sneezing or coughing
When examining the genitalia of a 3-year-old boy, which position is ideal?
Sitting position with knees spread and ankles crossed.
Which immunizations does the nurse ask about when interviewing a 75-year-old patient?
Tetanus and influenza
Which finding on a 2-month-old is considered abnormal and requires further follow-up?
The anterior fontanelle is not palpable
The student nurse is studying the changes a woman goes through during pregnancy. The student nurse knows that which body system undergoes the most dramatic physiologic changes during pregnancy?
The cardiovascular system
The nurse is performing an assessment on a newborn infant. The nurse will assess the infant's weight, length, and __ as part of this routine assessment.
head circumference
The nurse is assessing an 88-year-old woman who has a blood pressure reading of 160/90 mm Hg. This blood pressure reading indicates:
high blood pressure.
A 50-year-old woman tells the nurse that in the last year she has been very active in her community and is working with troubled youths. The nurse assesses the patient at which developmental stage?
Generativity versus stagnation
What is the nurse assessing when measuring from the patient's symphysis pubis to the top of the fundus?
Gestational age
An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent?
Guidelines for Adolescent Prevention (GAP)
The nurse is caring for a patient who presents to the clinic for her first prenatal visit. What priorities will the nurse focus the assessment on?
Healthy eating Teaching about body changes Establishment of baseline data Taking prenatal vitamins
The nurse is reviewing risk factors for respiratory infection with an older adult patient. Which physiologic change that occurs with aging predisposes the older adult to respiratory infections?
Mucous membranes become drier and more difficult to clear.
On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal?
The infant steps in place when held upright with feet on a flat surface.
What is an expected finding of the newborn's vision that the nurse teaches the parents?
The newborn is nearsighted and cannot see items unless they are close.
The daughter of an elderly patient is concerned because her mother has been falling lately. The nurse performs a head-to-toe assessment. Which finding indicates a need for further evaluation?
The patient appears agitated.
The nurse suspects a foreign body in a young child's nose. Which finding is most likely to cause the nurse to suspect this?
There is a foul-smelling odor coming from the child's nose.
The nurse is preparing to assess an older patient's ability to perform IADLs. Which statement about IADLs is true?
They are designed as a self-report measure of performance rather than ability.
The nurse suspects an infant has fetal alcohol syndrome. Which assessment finding is consistent for an infant with fetal alcohol syndrome?
Thin upper lip
The nurse is preparing to assess an older patient's basic activities of daily living (BADLs). What should be included in this assessment?
Walking Bathing Dressing
Which finding is considered abnormal during late pregnancy?
Watery vaginal discharge
A pregnant patient in her sixth month asks the nurse why her breasts are getting so big. The nurse's best response is, "The breasts enlarge during pregnancy because of":
an increase in the size and number of lactiferous ducts and breast alveoli.
