The nurse is visiting the day care center for routine assessment of the children. After spending time with the children in one of the playrooms, the nurse suspects that a child has a visual deficit as a result of observing:
1. Poor balance and gait
2. An increase in weight
3. Sitting and rocking back and forth
4. A failure to respond when touched
ANS: 3
Behaviors of children indicating a possible visual deficit include self-stimulation such as eye rub-bing, body rocking, sniffing or smelling, and arm twirling. Poor balance and gait may indicate an impairment of position sense in the adult. A weight change may indicate a deficit in taste in the adult. Failure to respond to touch may indicate a touch deficit in the adult.
You might also like to view...
A nurse is caring for a patient who just fell from the bed onto the floor. The nurse should write a(n)
1. Emergency record. 2. Incident report. 3. Progress report. 4. Grievance report.
A nurse assisting a new mother in the act of breast feeding is represented by which form of learning?
A) Affective B) Psychomotor C) Cognitive D) Simplistic
During a routine physical assessment for a 9-month-old client, the nurse notes swelling in the ankles. The nurse presses against the ankle bone for 5 seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation
Which system requires a more in-depth assessment based on these data? 1. Renal system 2. Musculoskeletal system 3. Respiratory system 4. Integumentary system
A patient is diagnosed with an abnormal potassium level. Which complication should the nurse assess for in this patient?
a. Cardiac arrest b. Fluid overload c. Internal bleeding d. Tetany with laryngospasm