Author Question: During an examination, a nurse asks a 5-year-old child to repeat his address. The nurse most likely ... (Read 74 times)

moongchi · **on:** Jun 27, 2018

During an examination, a nurse asks a 5-year-old child to repeat his address. The nurse most likely is evaluating:

1. Recent memory.
2. Language development.
3. Remote memory.
4. Social skill development.

Question 2

When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:

a. Tell the woman to stay home until her membranes rupture.
b. Emphasize that food and fluid intake should stop.
c. Arrange for the woman to come to the hospital for labor evaluation.
d. Ask the woman to describe why she believes she is in labor.

vseab · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

3
Rationale:
1. To evaluate recent memory, the nurse would have the child name something and then ask him to name it again in 1015 minutes.
2. Listening to how the child talks and his sentence structure helps evaluate his language development.
3. Asking children to remember addresses, phone numbers, and dates helps assess remote memory development.
4. Assessing how the child interacts with others helps evaluate social skill development.

Answer to Question 2

D
Feedback
A The initial nursing activity should be to gather data about the woman's status. The amniotic membranes may or may not spontaneously rupture during labor. The woman may be instructed to stay home until the uterine contractions be-come strong and regular.
B The initial nursing activity should be to gather data about the woman's status. After this assessment has been made, the nurse may want to discuss the appro-priate oral intake for early labor such as light foods or clear liquids, depending on the preference of the woman or her primary health care provider.
C Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview.
D Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data.