Pediatric and Older Adult prepU

An elderly client is very immobile, sitting in a chair most of the day or spending time in bed. Immobility greatly increases the client's risk for which of the following skin conditions?

Pressure ulcers

When applying the principle of ABC (airway, breathing, circulation) prioritization, which complication is priority for the nurse to address?

Aspiration pneumonia

Claire's daughter brings her in today after she fell at her home. Which assessments are indicated at this time?

All of the above

The nurse is preparing to conduct an admission assessment on an older adult client. What would be important to do before interviewing this client?

Reduce or eliminate background noise

Which of the following brief screening measures is useful in assessing memory?

Three-item recall

The nurse is conducting a functional assessment of an older adult client. The nurse should focus questions on which area?

Activities of daily living

In order to let an older adult client establish his or her cultural identity, which statement would be most appropriate for the nurse to make first?

"Tell me your beliefs about the illness you are experiencing."

The nurse is admitting an older male client diagnosed with congestive heart failure. Several risk factors for falls have been identified on the admission database. What is the nurse's best action to prevent falls?

Utilize safety alarms that are available on the unit.

When receiving the shift report, the nurse should identify which client as being at highest risk for falls?

73-year-old with confusion and incontinence

Which of the following represents an age-related change in the lungs?

Decreased chest wall compliance

When orienting a new staff nurse to the hospital unit, the charge should include which information?

Geriatric medical clients have an increased risk of falls while hospitalized.

What is the most common reason for admission of the older adult to the emergency department (ED)?

Falls

Which strategy can the nurse use to effectively approach the older adult client during the health history?

Have the room well-lit with minimal background noise

The family members of an elderly client tell the nurse, “He has lost his appetite. He eats very small amounts, and only twice a day.” Which suggestion would be most appropriate?

Recommend nutrient-dense foods.

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what?

Depression

An elderly client visits her community health clinic with an outbreak of vesicles on her skin. She tests positive for the herpes zoster virus. The nurse should recognize this condition as which of the following?

Shingles

A nurse assesses a client's blood pressure and the findings suggest orthostatic hypotension. Which area should the nurse emphasize during client education?

Prevention of falls

An older adult client has come to the clinic with new complaints of fatigue, constipation, and cold intolerance. The nurse would refer the client for what type of testing?

Assessment of thyroid function

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what?

Depression

A nurse assesses a client's blood pressure and finds orthostatic hypotension. Which area would the nurse emphasize as most important related to this finding?

Prevention of falls

The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?

Kyphosis

Which of the following indicates that an elderly client has been affected by polypharmacy?

Medications are used to counteract side effects of other prescribed medications.

The nurse is preparing to perform a pelvic examination on an elderly female client. What would the nurse expect to find?

Decreased vaginal secretions

While the nurse is interviewing a newly admitted older adult client, the client repeats the same story to the nurse several times. What is the nurse's next, best action?

Perform mini mental status exam

An older client asks why the leg muscles have become flabby over the last few years. What should the nurse respond to this client?

“It occurs with aging but is encouraged by sitting too much.”

When inspecting the toenails of an elderly client, an expected finding is:

Yellowed, thickened, lusterless nails

A nurse examines a frail elderly client's mouth and finds several broken and missing teeth and irritated gums. The nurse should assess this client closely for problems associated with which body system?

Gastrointestinal

A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old?

Knowing the person's baseline functional status and recognizing deviations from it

Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?

Fever

A hospitalized client develop thrombocytopenia. Which lab result does the nurse expect in this client?

Platelet count less than 100,000

A client has come to the clinic for a routine checkup. The client is 77 years old, weighs 198 pounds (89.8 kg) with a body mass index (BMI) of 34.1, stands 5'4” (162.5 cm), and lives alone. The client's B/P is 147/89, pulse is 80, and respirations 18. The nurse is planning client teaching. What is an appropriate topic to include in the teaching plan to best address health risks?

Encouraging a diet that supports a normal BMI

What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client?

Plan for additional time to allow as much independence as possible

Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar aspects of her forearms and on her abdomen. She otherwise has no complaints, and her diabetes and hypertension are well managed. Her son from out of state accompanies her today and has recently moved in to help her. What should the nurse suspect?

Elder abuse

An objective assessment that is frequently indicated when the subjective assessment reveals a history of falling is

a Get Up and Go test

When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

postural orthostatic hypotension

An older client demonstrates mental status changes after being diagnosed with a urinary tract infection. Which finding suggests that this client is experiencing delirium?

experiencing visual hallucinations

A nurse is preparing a class for a group of older adult clients at a local senior center. The nurse is focusing on health promotion and disease prevention. Which condition would the nurse most likely include as a common cause of infection-related deaths in the elderly?

Pneumonia

A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?

Left side-lying

A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is

the degree to which dyspnea affects daily function.

A nurse assesses an elderly client and determines that the client is at risk for falls. Which interventions are appropriate to reduce the incidence of actual falls the client incurs? Select all that apply.

• Remove rugs or other loose carpet

• Remind the client to ask for assistance

• Assist with exercise to strengthen lower extremities

A 76-year-old female client's blood pressure is 132/76 in a supine position, 128/71 when dangling at the side of her bed, and 105/58 when she is standing. These assessment findings constitute a risk for which of the following health problems?

Falls

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record?

Stress

An older female client who is hospitalized requires frequent linen changes due to incontinence when they cough or sneeze. How should the nurse document the client’s incontinence?

“The client requires frequent linen changes due to stress incontinence.”

A sign of infection in the elder that is more common than fever is

confusion

Any new onset of incontinence in the frail elder should be investigated for

urinary tract infection

The nurse notes that it takes an older client 45 seconds to complete the “get up and go” test. Which activities of daily living should the nurse plan to assist the client with completing? Select all that apply

• Bathing

• Climbing stairs

• Getting in and out of bed

With a client suspected of suffering from presbycusis, the nurse would expect difficulty hearing:

High-pitched sounds

The nurse has assessed and informed the healthcare provider of a brown-colored lesion on an older client's left cheek. The lesion is diagnosed as solar lentigines. What is the nurse's best action?

Encourage the client to wear sunscreen daily

Half way through a shift, a nurse reassesses an elderly client who was admitted with uncontrolled hypertension the day before. On reassessment, the nurse has difficulty palpating the client’s right pedal pulse, which had been palpable and equal to the left pedal pulse at the start of the shift. What is the priority action of the nurse?

Notify the health care provider

It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause?

Delirium

The nurse is collecting a history on a 4-year-old and discovers that the child is being cared for by his grandmother during the days while the parents are at work. The grandmother's house was built in the early 1940s. Which lab should the nurse prepare to collect from the child?

Lead level

A nursery nurse is assessing the neurologic status of a newborn. What area would the nurse be assessing?

Reflexes

Parents of an Hispanic newborn express concern about the "bruise" they see on the lower back of their child. What explanation by the nurse can alleviate the parents' concern?

"This is called a slate gray nevus and is common in infants of African, Hispanic, or Asian descent."

A nurse is having difficulty getting a 14-year-old child to “open up” during the health interview. What strategy is most likely to enhance the nurse's communication with this child?

Give the child some control over the course and content of the interview.

The nurse is assessing a 3 year old child's eyes and should notify the healthcare provider immediately when observing which finding?

Unequal and nonreactive pupils

A woman brings her 7-year-old daughter to the clinic. The mother says the child has been complaining of increasingly severe right lower quadrant abdominal pain for the past 2 days and has stayed home from school. What would the nurse suspect is wrong with the child?

Appendicitis

A parent of an ill infant states, “We've gave him ibuprofen for a fever and he had an allergic reaction.” Which response would be most appropriate?

"Describe what happens to him when he takes ibuprofen."

During the assessment of a 2-month-old infant's reflexes, the nurse placed a finger in the baby's hand and pressed against the palm. The baby flexed all fingers to grasp the nurse's finger. How would the nurse document this finding?

Palmar grasp reflex intact

The nurse is caring for a hospitalized infant. Assessment of the baby reveals decay in the two upper front teeth. What education can the nurse provide to the baby's parents to prevent further problems with the teeth?

Do not allow the baby to go to sleep with a bottle of milk, formula, juice, or any other sugary drink

During the physical exam, Sasha, a 12-month-old, cries and continually reaches for her mother. How does the nurse interpret Sasha’s behavior?

The nurse recognizes that this is an expected finding.

A new mother asks why the baby can lift the head without problems but seems to be slower when moving the legs. What should the nurse respond to this mother?

“Development occurs centrally or from the head to the periphery or the arms and legs.”

The mother of a newborn is concerned that “something is wrong” with the baby’s eyes because the pupils are small. What should the nurse respond to this mother?

“A newborn’s pupils are small because eye function is not fully developed yet.”

A mother of a 4-year-old asks the nurse when the child will begin to lose his baby teeth. What is the correct response by the nurse?

“Baby teeth will begin to be replaced by permanent teeth about age 6 years.”

The client is an adolescent girl. When weighed, the client falls below the 5th percentile for her height. The nurse notes that the client is so thin that her bony skeleton is readily observable. She has delayed sexual development. What would the nurse first suspect?

Anorexia nervosa

A nurse is evaluating reflexes in a newborn. The nurse gently strokes the cheek, and the newborn turns toward the stimulus and opens the mouth. What reflex is the nurse testing?

Rooting

A mother brings her 2-month-old infant to the health care clinic because she has noticed a bulge at the umbilicus that seems to get bigger when the baby cries. That nurse recognizes this as what type of finding?

Umbilical hernia

A nurse assesses a 9-month-old with otitis. It is this client's third case in the past 6 months. Otitis media is a risk factor for which of the following?

Hearing loss

On inspecting a newborn's breasts, the nurse notes that they are enlarged and engorged, with a white liquid discharge. The infant's mother is concerned about it. Which of the following should the nurse tell the mother regarding this finding?

It is due to the influence of the maternal hormones and should resolve in a few days.

A parent of an ill infant states, "We gave him ibuprofen for a fever, and he had an allergic reaction." Which response would be most appropriate?

"Describe what happens to him when he takes ibuprofen."

A teenage client comes to the clinic. He tells the nurse that he attends parties every weekend where alcohol is served. What is the most appropriate topic for client teaching?

Drinking and driving

What is an appropriate action by a nurse when asking a child about the presence of pain?

Use a pain scale appropriate for the child's developmental level

A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness in order to facilitate completion of the exam?

Allow the child to place their hand under the examiner's hand

When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen. What would be most appropriate for the nurse to do?

Palpate with the child's hand under the nurse's hand.

During assessment of a 2 year old child, which assessment by the nurse would best indicate possible hydrocephalus?

Head circumference

The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination?

Unstable gait

When the nurse palpates the neck of an infant, he notices crepitus at the right clavicular area. The infant also exhibits decreased movement in the right arm. Which of the following would the nurse suspect?

Fractured clavicle

A nurse assesses 2-month-old child. Which of these parameters should a nurse identify as biologic developmental variation in childhood when assessing a 2 month old infant?

Body size and proportion

The nurse is performing a routine newborn assessment and gently strokes the cheek of the baby. The newborn turns toward the stroke and opens the mouth. What is this reflex called?

Rooting reflex

The nurse is caring for a 2-month-old infant who has the following vital signs: temperature reading of 98.6° F (37° C); heart rate 122 bpm; respiratory rate 28 breaths per minute. The nurse should:

Do nothing, as the infant’s vital signs are within normal limits.

During examination of a newborn, the nurse presses her finger against the newborn's palm and the newborn grasps the finger. What reflex is the nurse eliciting from this action?

Palmar

Upon assessment of the child's eyes, they deviate inward. The nurse recognizes this as what?

Esophoria

A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention?

Raise head of bed and apply oxygen

While attempting to auscultate heart sounds a 2-year old client pushes the nurse’s hand away. What should be done to facilitate this assessment?

give the child something to hold in each hand

The nurse is assessing the heart rate of a 5-year-old client. The client’s heart rate is assessed at 100 beats per minute at rest, which the nurse determines as which of the following?

within normal limits

A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?

Apical pulse is less than 100 beats per minute

A parent of an ill infant states, “We gave him ibuprofen for a fever, and he had an allergic reaction.” Which response would be most appropriate?

“Describe what happens to him when he takes ibuprofen.”

The nurse learns that a new mother was upset after hearing about being pregnant and did not look forward to the birth of the baby. On what should the nurse focus when assessing the mother and the baby?

Emotional attachment

One of the Healthy People goals for children and adolescents is to reduce the proportion who are overweight or obese. What intervention by the school nurse would help to meet this goal?

Go to each class and give a presentation with discussion of healthy snacking and exercise.

A nurse should implement which important criterion to promote an effective nurse–parent communication when conducting a parent interview as a part of the child assessment?

Allow privacy for interview

The nurse is experiencing challenges in eliciting information during the health interview of a 4-year-old boy. How can the nurse best foster communication with the child?

Actively engage the child in play.

The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate?

Denver Developmental Screening

What question should the nurse ask in order to assess an adolescent’s risk factors for obesity and deficient nutritional status?

“What do you eat in a typical day?”

It is often difficult to assess the location of pain in a child because generally children cannot

isolate their pain

A nurse is presenting a class for new parents about infant care. Which of the following positions would the nurse emphasize as important in decreasing the risk of sudden infant death syndrome?

Supine

Which of the following would be most appropriate when assessing a newborn's rooting reflex?

Touch the lip or cheek with a gloved finger

A newborn appears to be in respiratory distress with a respiratory rate of 70 breaths/min, nasal flaring, and intercostal retractions. The newborn has a temperature of 37.2°C (98.9°F;) and a pulse rate of 190 beats/min. What is the normal range for a newborn's heart rate?

120-160 beats/min

A group of students is preparing a class presentation on infant sleeping and Sudden Infant Death Syndrome. The presentation would include which of the following?

Teach parents about placing the baby on his back to sleep

During examination of a newborn, the nurse strokes the lateral edge and ball of the newborn’s foot so that the toes fan. What reflex is the nurse eliciting from this action?

Babinski

When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen. Which of the following would be most appropriate for the nurse to do?

Palpate with the child's hand under the nurse's hand.

A parent tells the nurse, "I am worried about my 13-year-old son. He hasn't started puberty yet and my daughter did when she was 11 years old.” Which response by the nurse would be most appropriate?

"The onset of puberty is normally earlier in girls."