The nurse is observing a 4-year-old child playing in the play room, and determines the child is meeting normal developmental milestones when the child:
1. Eats with her fingers.
2. Draws a picture of a person with three parts.
3. Ties her shoes and buttons her shirt.
4. Can count to four.
3
Rationale: The 4-year-old who ties her shoes and buttons her own buttons is meeting developmentally appropriate milestones. Anticipated milestones would include eating with a fork and spoon, drawing a picture of a person with six parts, and counting to at least 10.
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During the health history, the patient informs the nurse that her mother has diabetes. What is the significance of this information?
A) The patient may be at risk for developing diabetes. B) The patient may need teaching on preventing diabetes. C) The patient may need to attend a support group for diabetes. D) This may affect the patient's diet during hospitalization.
The nurse caring for a 19 year-old patient with Down syndrome who is admitted to the hospital with pneumonia recognizes that this patient's disability is categorized as:
A) A sensory disability B) A developmental disability C) An acquired disability D) An age-associated disability
What should the nurse do during the evaluation phase of the nursing process?
A) Have patient provide input on quality of care B) Discontinue surgical sutures C) Provide follow-up appointment for postoperative patient D) Document improved gas exchange with incentive spirometry use
During which of the following types of anesthesia should the nurse expect the client to maintain a gag reflex during surgery?
A. Inhalation of general anesthesia B. Intravenous general anesthesia C. Balanced anesthesia D. Regional anesthesia