The nurse knows that a normal finding when assessing the respiratory system of an older adult is:
a. Increased thoracic expansion.
b. Decreased mobility of the thorax.
c. Decreased anteroposterior diameter.
d. Bronchovesicular breath sounds throughout the lungs.
ANS: B
The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.
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A) Neurological system B) Urinary system C) Respiratory system D) Gastrointestinal system
A school nurse is conducting a health education class for middle school girls. The nurse knows further teaching is needed if a student states:
1. "I should begin to see hair in the pubic area before my breasts start to develop." 2. "I understand that girls develop earlier than boys." 3. "I understand that sexual maturity can vary as to when it occurs." 4. "The beginning of breast development is around 10 years of age for Caucasian girls."
The emergency department nurse assesses a middle-aged mountain climber who reports headache, nausea, vomiting, and "feeling winded." What is the nurse's priority intervention?
a. Administer acetazolamide (Diamox). b. Administer prochlorperazine (Compazine). c. Perform a neurologic assessment. d. Assess for bowel sounds.
The nurse is reviewing a client's care plan. Which part of the nursing process should the nurse use to determine if new problems exist?
A. Implementation. B. Assessment. C. Evaluation. D. Planning.