Deck 3: Health Assessment Across the Lifespan

Question 1

The parent of a 3-year-old child voices concerns about the child's potential developmental delays.The parent reports an older child reached milestones significantly ahead of the younger child.An assessment reveals the child is able to assist with dressing and can play catch.Which of the following responses by the nurse is appropriate?
1)"Your child appears to be on target with the expected milestones for age."
2)"Your older child may simply be smarter than your 3 year old."
3)"I would recommend extensive testing to determine the source of the delays."
4)"Have you spoken with the health care provider about these delays?"

Answer 1

1

Question 2

A preschool-age child is at play.Which of the following behaviors indicates to the nurse that the child is successfully moving through Piaget's cognitive stages of development appropriate for this age?
1)The child is able to consider the differing opinions of playmates.
2)The child is able to recall the good time experienced the previous weekend at the playground and is anticipating going there again the following week.
3)The child reports being able to rationalize why it is better to eat fruit than candy.
4)The child understands that his mother loves him as much as she loves the child's older siblings.

Answer 2

2

Question 3

The adult children of an older adult client report they are becoming frustrated.They relate they are trying to get their parent to "take it easy";stop working and reduce social activities.When questioned by the nurse,they report feeling this lessened stress will protect their loved one.Which of the following statements should be included in the nurses responses?
1)"Keeping busy will assist your parent to remain productive."
2)"Older adults who lack intellectual challenges may demonstrate cognitive declines."
3)"Your plans will increase your parent's quality of life."
4)"Retirement will promote rest and relaxation for your parent."
5)"It is important for older adults to have opportunities to develop and maintain friendships."

Answer 3

1,2,5

Question 4

Using Piaget's theory of cognitive development,the nurse expects preschoolers will:
1)Be egocentric and fail to see another's point of view.
2)Focus on many aspects of a given situation at once.
3)Assume everyone else in their world sees things as they do.
4)Believe they have magical powers of thought to control the universe.
5)Understand cause-and-effect relationships

Question 5

The mother of a toddler tells the nurse that she is concerned about her child's lower back curving in and the child's belly sticking out.Which of the following actions would be appropriate for the nurse?
1)Suggest that the mother to buy the child bigger clothes.
2)Give the mother the first available appointment to see the health care provider.
3)Contact the health care provider to see if an orthopedic referral is necessary.
4)Reassure the mother that this is normal for a toddler.

Question 6

In preparation for a sport's physical examination,the nurse is assessing the height of a 16-year-old male client.The client measures 5′5″.The client voices concerns about his lack of stature.He asks if he has reached his full height.Which of the responses by the nurse is most appropriate?
1)"By age 16,you are finished growing."
2)"Is your father very tall?"
3)"Why do you hope to grow taller?"
4)"You may continue to grow into your early 20s."

Question 7

The nurse is talking with an older adult client who has recently retired after 45 years of working as an executive at the same company.Which of the following demonstrates to the nurse that the client is adjusting to this new phase of life?
1)The client spends most of the day at home and declines invitations to outside gatherings with friends because there is "so much to do" at home.
2)The client has enrolled in courses at the local university to complete the college degree that was started "years ago," but interrupted by family responsibilities.
3)The client has lunch at the company cafeteria several times each week.
4)The client has purchased hearing aids,but rarely uses them.

Question 8

During a well-baby visit,the nurse measures the height and weight of an infant and plots the measurements on the baby's growth chart.The nurse notes a slowed growth pattern.Which of the following would be an appropriate action for the nurse to take?
1)Obtain an endocrinologist referral.
2)Perform a nutritional assessment.
3)Wait until the next visit to intervene.
4)Assess for circulatory problems.

Question 9

The nurse is interviewing the mother of a toddler who verbalizes concerns that her child uses the toilet to void,but refuses to use the toilet for bowel movements,and often hides to defecate.The nurse identifies that this child is in which of the following Freudian phases of psychologic development?
1)Genital
2)Phallic
3)Anal
4)Latency

Question 10

During a routine physical examination,a middle-aged female client reports concern about the weight gained over the past 2 years despite not having made any significant changes in diet or exercise patterns.The nurse understands that which of the following factors may be responsible for the client's reported changes in weight?
1)The client's increasing hormone levels
2)The client's increase in body mass index
3)The reduction in muscle nerve conduction
4)The hormonal changes of the female climacteric

Question 11

An older adult presents to the clinic for a routine physical examination.The client reports having trouble with memory and often has to "search" for words when having a conversation with friends or family.Which of the following assessment tools will help the nurse to gather more data about this client's concerns?
1)The Denver II
2)Mini-Mental Status Examination
3)Life Experiences Survey
4)Hassles and Uplifts Scale

Question 12

When reviewing the developmental behaviors of an 8-month-old infant,which of the following behaviors indicates to the nurse the need for follow-up assessments?
1)Unable to sit for brief periods of time without support
2)Moro reflex present
3)Crawling on abdomen
4)Pulls self to standing position
5)Positive Babinski reflex

Question 13

The nurse is conducting a prenatal class to expectant parents.When one of the couples asks how children grow,the nurse explains that growth and development proceeds in a number of ways.Which of the following descriptions will the nurse use to accurately reflect normal growth and development?
1)Cephalocaudal direction
2)Simple to complex
3)Distal to proximal direction
4)Generalized response to specific response
5)Anterior to posterior

Question 14

During a well-baby check the nurse notices the infant does not demonstrate the expected developmental milestones for this age.Which of the following nursing interventions should be completed first?
1)The nurse should initiate a consult with social services for a home assessment.
2)The nurse should consult with the health care provider.
3)The nurse should ask the parents questions about their play activities with the infant.
4)The nurse should prepare the family for a potentially upsetting diagnosis.

Question 15

The nurse is teaching the parents of a child who is in Piaget's sensorimotor stage of development.Which statement,made by the parents,indicates to the nurse that they understand the teaching and are working appropriately to help the child accomplish developmental tasks of this stage?
1)"We have started buying more colorful toys."
2)"We play with water toys in the bathtub."
3)"We bought some blocks with numbers."
4)"We have been playing peek-a-boo."

Question 16

The nurse working at an assisted living facility has just counseled a client experiencing a crisis in Erickson's developmental stage of integrity versus despair.Which of the following suggestions by the nurse would be most appropriate to assist this client?
1)"You should consider buying a bigger house so that your divorced son can come and live with you."
2)"You should consider getting a job to fill your time."
3)"You should organize your family photos into an album"
4)"You should consider playing a sport."

Question 17

Just after an appointment with the health care provider,an older adult client asks the nurse,"Why can't I seem to exercise like I did when I was younger? I just don't have the endurance that I did when I was 45,even though I feel good.The health care provider says I'm in good health and can exercise,but do you think there could be something wrong with me?" The nurse's best response to this client's statement is:
1)"I think you should discuss this further with the health care provider;maybe you need more tests."
2)"As individuals get older,there are normal changes that occur in the body,specifically the heart and lungs,that may contribute to decreased endurance."
3)"The health care provider cleared you for exercise.I'm sure you are fine."
4)"The body undergoes physiologic changes that can affect your endurance,such as decreased cardiac output and increased residual air volume in the lungs."

Question 18

An older adult client voices concerns to the nurse regarding the seemingly continued loss of family and friends to illness and death.The client states,"God is cruel.I have no one anymore.I am too old to make new friends;it's useless,everyone leaves me." Using Erickson's psychosocial theory,the nurse interprets the client's remarks.This client is:
1)Successfully mastering the stage of integrity versus despair.
2)Is having difficulty passing through the stage of generativity versus stagnation.
3)Is experiencing struggles to succeed in the stage of integrity versus despair.
4)Is demonstrating unsuccessful completion of the intimacy versus isolation stage of development.

Question 19

The nurse identifies which of the following as environmental factors that can influence the growth and development of an individual?
1)Nutrition
2)Climate
3)Heredity
4)Culture
5)Religion

Question 20

The mother of a 5-month-old infant calls the pediatrician's office to report to the nurse that she has noticed that her infant still has tremors of the extremities and chin at times.Which of the following actions would be appropriate for the nurse?
1)Reassure the mother that these tremors are a normal part of the infant's development.
2)Give the mother the first available appointment to see the health care provider.
3)Contact the health care provider to see if an electroencephalogram (EEG)should be ordered.
4)Ask the mother to keep a diary of the tremors and schedule an appointment for next week.

Question 21

The nurse is explaining the influence of culture on growth and development to a group of expectant first-time parents.The nurse recognizes the need for further teaching when a parent states:
1)"Mothers and fathers should always share in the responsibilities of caring for a new baby."
2)"Culture may influence the rate at which developmental milestones occur."
3)"The ways in which children are disciplined may vary among cultures."
4)"The value of education varies among cultures."

Question 22

The nurse is counseling a middle-aged couple when the man asks if his wife is going through menopause.His wife has told him that both men and women experience decreasing hormonal production during middle adulthood,and he asks the nurse if this is true.What is the most appropriate response by the nurse?
1)"Your wife has obtained some incorrect data."
2)"Why do you ask?"
3)"Your hormonal levels increase,not decrease with age."
4)"Your wife is correct.Both men and women experience a decrease in hormone production with aging."

Question 23

The nurse is completing discharge teaching to the family of a hospitalized older adult client.Which of the following is most important for the nurse to include in this teaching plan?
1)Reducing the amount of odor in the client's immediate environment
2)Protecting the client from injury due to increased pain threshold
3)Speaking in an increasingly loud voice as client's hearing decreases
4)Avoiding range of motion exercises due to loss of bone density and increased risk for fracture

Question 24

The nurse is caring for a young adult client in the clinic who presents for a routine health examination.The nurse anticipates which of the following interventions for this client?
1)Counseling on injury prevention
2)Tetanus/diphtheria vaccination booster
3)Counseling on fluoride supplements
4)Information on diet and exercise
5)Fecal occult blood test

Question 25

The nurse is caring for a hospitalized infant.When the infant begins to cry,the parents report they do not believe in responding too rapidly,as they do not wish to spoil their child.Which of the following responses by the nurse is most appropriate?
1)"I agree with your philosophy of child rearing."
2)"There are many studies that support this belief."
3)"Responding quickly to your baby's cries will assist the baby in feeling secure and does not result in a spoiled child."
4)"Children who experience separation anxiety have been spoiled by their parents."

Question 26

Which of the following assessment findings in an older adult client does the nurse associate with the normal aging process?
1)Increased systolic blood pressure
2)Increased muscle tone
3)Decreased cardiac output
4)Increased vital capacity
5)Decreased renal function

Question 27

An infant has been admitted to the pediatric unit for observation.The admission assessment indicates the family is Cuban American.When assessing the family's interactions the nurse notes the mother does all the care of the child while the father seems detached from the infant.Which of the following would be the most appropriate nursing diagnosis in this situation?
1)Compromised family coping
2)Altered role functions
3)Risk for family violence
4)Readiness for enhanced family processes

Question 28

The nurse is counseling the parents of a young teenager who is experiencing behavioral problems.The nurse would correctly choose which of the following assessment tools in this situation?
1)Family Psychosocial Screening
2)Eyeburg Child Behavior Inventory
3)Ages and Stages Questionnaire
4)Child Development Inventory

Question 29

The father of a preschool-aged child tells the nurse he is concerned that his son cannot ride a tricycle.Which of the following actions would be appropriate for the nurse?
1)Reassure the father that this is normal.
2)Refer the child to the health care provider.
3)Perform further growth and development assessments.
4)Ask the father about any siblings and at what age they rode a tricycle.