Which child would the nurse suspect as having a developmental delay?
A) A 5-month-old who does not sit unsupported
B) An 11-month-old who does not pull himself to a standing position.
C) A 3-month-old who cannot grasp an object voluntarily.
D) A 12-month-old who cannot build a tower of 8 blocks.
B
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A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?
a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg
An older Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood. Which action by the nurse is most appropriate?
a. Include a shaman when planning the patient's care. b. Avoid direct eye contact with the patient during care. c. Ask the patient about any special cultural beliefs or practices. d. Involve the patient's oldest son to assist with health care decisions.
Which auditory structure has, as an effect of aging, an increase in cerumen, drier cerumen, and an increase in hair?
A. auditory nucleus B. middle ear C. external ear D. inner ear