NUR 1020C Exam 2 Questions With Complete Solutions
3-4 Months Hearing Correct Answer Acoustic blink reflex,
infant stops movement andappears to "listen," stops sucking,
quiets if crying, cries if quiet
5 rights of delegation Correct Answer 1. Right task - within
scope of practice and within caregiver scope of practice
2. Right circumstance - consider how stable the patient is, safety
3. Right person - must have knowledge and skills, demonstrate
competency, certification and licensure , consider how stable the
patient is
4. Right direction/communication - Clear Concise Complete
Correct
5. Right supervision/evaluation - Monitor progress, give feed
back, intervene when needed, evaluate outcomes
Specific task at a specific time
6-8 Month Hearing Correct Answer Infant turns head to
localize sound, responds to own name
ABCDEF Skin Assessment Correct Answer A: asymmetry
B: border irregularity
C: color variations
D: diameter greater than 6 mm (pencil eraser)
E: elevation or evolution
F: funny looking—"ugly duckling" —different from others
Abdomen divided into 4 quadrants Correct Answer RLQ
RUQ
,LUQ
LLQ
Abduction Correct Answer Movement away from the midline
of the body
Able to Perform Self Care Correct Answer Supporting Data:
Patient able to get out of bed and stand at sink, patient
expressing a desire to be independent in ADLs
Abnormal Conditions of the Nails Correct Answer Scabies
Paronychia
Beau lines
Splinter hemorrhages
Onychomycosis
Late clubbing
Pitting
Habit-tic dystrophy
Abnormal findings abdomen Correct Answer Hernia: A
bulging of an organ or tissue through an abnormal opening.
Abnormal Hair Conditions Correct Answer Toxic alopecia
Tinea capitis (scalp ringworm)
Traction alopecia
Seborrheic dermatitis (cradle cap)
Pediculosis capitis (head lice)
Folliculitis barbae ("razor bumps")
Hirsutism
Furuncle and abscess
,Additional Health History Questions (aging adult) Correct
Answer What changes have you noticed in your skin in past few
years?Any delay in wound healing?
Any other skin pain?
Any change in feet: toenails, bunions, wearing shoes?
Have you had any falls?
History of diabetes or peripheral vascular disease?
What do you do to care for your skin?
Additional Health Questions Aging Adult Bone Correct Answer
Use functional assessment history questions to elicit any loss pf
function, self care deficit or safety risk
New onset weakness
Increase in falls or stumbling
Use of mobility device
** Recommendation for DXA (bone density test) screening for
females ages 65 and older and postmenopausal women younger
than 65 of age who are increased risk
Additional History Infants and Children Correct Answer -
Maternal and/or fetal problems during pregnancy and delivery
- Gestational status, birth weight, and Apgar score
- Reflexes and motor performance
- Presence of seizure activity
- Meeting developmental milestones
- Environmental exposure to lead
- learning problems identified
- Significant family history
- Participation in sports—injury history/screen for concussion
, Adduction Correct Answer Movement toward the midline of
the body
Adolescents Correct Answer Secretions from apocrine sweat
glands increase
Subcutaneous fat deposits increase
Secondary sex characteristics
Adults Children Caregivers Correct Answer Adult children are
often caregivers for their elderly parents.
Most adult children caregivers are in the "sandwich
generation"—they must care for their children as well as their
parents, either in their own home or in the home of their parents.
Advocacy Correct Answer Advocacy involves defending the
rights of others, especially those who are vulnerable or unable to
make decisions independently
After 65 years of age Correct Answer Loss of sensation of
vibration at ankle malleolus common; loss of ankle jerk; tactile
sensation may be impaired; may need stronger stimuli for light
touch; and especially for pain Perform bilateral comparison
Aging Adult Eyes Correct Answer Visual fields narrow and
depth perception is distorted(especially climbing/descending
stairs)
• Pupils are smaller, reducing night vision
• Lens yellow and become opaque, resulting in distortion of
green, blue and violet tones; and increased sensitivity to glare
• Production of tears decrease so eyes feel dry or burn
PREVENTION:
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