Test 3 REVIEW

Question 1

What is one reason for the “middle-aged spread” often seen in middle adults?

Answer 1

Decreased physical activity

Question 2

A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?

Answer 2

Stroke

Question 3

A male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?

Answer 3

Assess the client’s temperature by axilla.

Question 4

According to Erikson, normal adolescent behavior includes trying on new roles and possibly even rebelling. What is the purpose of this behavior in adolescents?

Answer 4

To establish a sense of identity

Question 5

A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured?

Answer 5

Rectal

Question 6

A nurse is taking a client’s temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Answer 6

Rectal

Question 7

A home health care nurse notices that his assigned client uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is NOT correct?

Answer 7

“Just flush the glass and mercury down the toilet.”

Question 8

Which of the following is an average normal temperature in Centigrade for a healthy adult?

Answer 8

oral: 37.0 degrees C

Question 9

All humans learn from both formal and informal experiences. What orderly pattern of changes results in part from learning?

Answer 9

Development

Question 10

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

Answer 10

Tachycardia

Question 11

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Answer 11

Reading is erroneously high

Question 12

A girl age 18 years has chosen not to attend a party in which alcohol will be consumed. Which value system is she most likely adhering to?

Answer 12

Law-and-order orientation

Question 13

A child gains weight and becomes taller each year. What is this process called?

Answer 13

Growth

Question 14

A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer?

Answer 14

Convection

Question 15

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

Answer 15

The blood pressure increases.

Question 16

The staff at a long-term care facility have made minimal effort to secure a shared room for a couple…who have been married for several decades. The manager states, “I’m sure that bedroom activity in…their mind these days.” How should the nurse best respond to the manager’s…?

Answer 16

“They might not be as active as in years past, but sexuality is still important for older people.”

Question 17

A mother brings her toddler, age 20 months, to the clinic today for immunizations. She talks about trying to initiate toilet training a few weeks ago, but her son wasn’t interested. She decided to put it off for awhile. She told her son was a good boy and they would try again another time. According to Erik Erikson’s theory, what is the likely outcome for Matt’s developmental stage?

Answer 17

Autonomy

Question 18

A child 2 years of age is hospitalized for a surgical procedure. Although previously all fluids were taken from a cup, the toddler wants a bottle to suck on. The nurse recognizes this behavior as what?

Answer 18

Normal regression

Question 19

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?

Answer 19

Tachycardia

Question 20

What anatomic site regulates the pulse rate and force?

Answer 20

Cardiac sinoatrial node

Question 21

A nurse is explaining ADHD to a community parents group. What characteristics of this disorder are exhibited by an affected child?

Answer 21

Inattention, impulsiveness, hyperactivity

Question 22

A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use?

Answer 22

Radial

Question 23

Which of the following statements is true of the older adult population?

Answer 23

Incontinence is not a part of aging

Question 24

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

Answer 24

Systolic pressure

Question 25

A school nurse often observes adolescents challenging the decision making of their parents and teachers. Which of these developmental theorists relates this as an expected occurence?

Answer 25

Piaget

Question 26

What site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious?

Answer 26

Oral

Question 27

A middle adult client requests visits by the hospital chaplain and reads the Bible each day while hospitalized for treatment of heart problems. What is the individual illustrating?

Answer 27

Trust in spiritual strength

Question 28

What social group prepares the school-aged child to get along in the larger world and teaches appropriate sex role behavior?

Answer 28

Peers

Question 29

A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?

Answer 29

“Put away the salt shaker and eat low-salt foods.”

Question 30

A nursing student is assisting the school nurse with a middle school health fair. The student does height and weight assessments on the students. As the nursing student assesses them, the student observes that the students are … deductive reasoning and think in abstract ways. According to Piaget, in what development state are they?

Answer 30

Formal operational

Question 31

A nurse is educating the parents of an infant about possible health problems during infancy. Which of the following health problems during infancy is most serious?

Answer 31

SIDS

Question 32

In general, what is the focus of care for nurses who work with older adults?

Answer 32

Assisting clients to function as independently as possible

Question 33

Which is the primary source of heat in the body?

Answer 33

Metabolism

Question 34

A nursing student is observing in a pediatric clinic. A grandmother brings an infant age 2 months to be seen. The infant has failed to gain the expected amount of weight and looks unwell. The nursing student wonders if this may be a failure to thrive baby. Which one of the following has been linked to failure to thrive babies?

Answer 34

Nutritional deprivation

Question 35

A boy age 4 years is constantly seeking out and exploring new experiences, and repeatedly asking his parents why-type questions. The boy’s behavior suggests that he is successfully navigating an important developmental task within the development theory of:

Answer 35

Erikson

Question 36

While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude?

Answer 36

These are normal physiologic changes of aging.

Question 37

A nurse is developing a plan of care for an older adult with chronic heart disease. Which of the following factors should be considered?

Answer 37

Medications, hospitalizations, and medical supplies increase economic difficulties.

Question 38

What population is at greatest risk for hypertension?

Answer 38

African American

Question 39

A student is reading the medical record of an assigned client and … What does this “…” indicate?

Answer 39

Normal body temperature

Question 40

Which of the following clients should the nurse monitor vital signs every four hours?

Answer 40

A client hospitalized for high blood pressure

Question 41

A nurse is teaching a group of parents about the dangers of Sudden Infant Death Syndrome (SIDS). The nurse recommends that parents place their children on a firm surface laying on their:

Answer 41

back

Question 42

A nurse is providing care to an older adult at home after major abdominal surgery. Which of the following nursing diagnoses would most likely be appropriate?

Answer 42

Risk for Infection

Question 43

The nursing student is visiting a middle school with an assignment to observe and visit with students while walking around with the school nurse. The nursing student is interested to learn that some students seem to be rebelling against authority figures like teachers and parents. The nursing student recalls that, according to Erikson’s theory, this is not abnormal behavior. To which stage of Erikson’s theory does this behavior belong?

Answer 43

Identity versus role confusion

Question 44

A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing dis… is most appropriate to describe the client’s condition?

Answer 44

Dyspnea

Question 45

A nurse walks into a client’s room and finds him having difficulty breathing and complaining of chest pain. … bradycardia and hypotension. What should the nurse do next?

Answer 45

Report findings to the physician immediately.

Question 46

A child demonstrates increasing language skills and an understanding of symbols. Creative play and the use of imagination is an important activity in the child’s life. Based upon these characteristics and according to Jean Piaget’s theory, what stage of cognitive development is the child demonstrating?

Answer 46

Preoperational stage

Question 47

The emergency department nurse is caring for an infant age 2 months 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 a 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?

Answer 47

Trust

Question 48

The nurse is educating a Young Childcare class and one of the parents asks what kinds of actions on this part may increase safety for his 14-month-old daughter during the next 2 years. Which of the following responses would be appropriate? Choose all that apply.

Answer 48

• Keep medications locked away. /
• Keep plastic bags out of reach.
• Use approved car seats. /
• Do not swing by arms or legs

Question 49

Which of the following statements accurately describes factors that may affect an individual’s growth and development? Select all that apply.

Answer 49

• Physical characteristics such as height, bone size, eye color, and hair color are inherited from the family of origin.
• Fetal development can be altered by maternal age, inadequate maternal nutrition or substance abuse.
• Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships, low self-esteem, and poor social skills.
• Infants who are malnourished in utero develop fewer brain cells than infants who have had adequate prenatal nutrition.

Question 50

One of the adverse events that Medicare will no longer reimburse the hospital for is an in-hospital fall. Fall prevention is a major part of nursing and risk management. In order to reduce the risk of falling, the nurse must:

Answer 50

• ensure that the patient wears his prescription glasses when up.
• post signs to alert staff to the patient at high risk for falls.
• assess the patient’s fatigue level.
• monitor gait and balance.