Health assessment of infant, preschool, school going, adolescent, adult, antenatal, postnatal women and elderly
Time: 15:00
When assessing a newborn, the nurse elicits the Moro reflex. What is the primary significance of a normal Moro reflex?
[a] It indicates the infant's ability to feed effectively.
[b] It is the best indicator of the infant's visual acuity.
[c] It assesses the integrity of the central nervous system.
[d] It determines the strength of the infant's lower extremities.
During the health assessment of an infant, why is the serial measurement of head circumference a critical component?
[a] To determine the infant's nutritional status.
[b] To monitor brain growth and detect potential abnormalities like hydrocephalus or microcephaly.
[c] To predict the infant's future height and weight.
[d] To assess the infant's hearing capabilities.
Which finding would be considered normal when assessing the anterior fontanelle of a healthy, calm 6-month-old infant?
[a] Bulging and tense
[b] Sunken and depressed
[c] Soft, flat, and level with the surrounding skull bones
[d] Completely closed and ossified
A nurse is assessing a 4-year-old preschooler's vision. Which tool is most appropriate for this age group?
[a] A standard Snellen eye chart with letters.
[b] An Allen chart with pictures or a "Tumbling E" chart.
[c] A pupillary response test with a penlight only.
[d] Asking the child if they have trouble seeing.
What is a key principle for a nurse to follow when conducting a physical assessment on a preschool-aged child?
[a] Perform the most invasive procedures first to get them over with.
[b] Separate the child from the parent to ensure complete focus.
[c] Use play therapy and allow the child to handle the equipment before use.
[d] Use complex medical terminology to prepare them for future visits.
During a health assessment of a 10-year-old school-going child, the nurse asks the child to bend forward at the waist with arms hanging freely. What condition is the nurse primarily screening for?
[a] Lordosis
[b] Kyphosis
[c] Poor muscle tone
[d] Scoliosis
When assessing a school-aged child, it is important for the nurse to:
[a] Address all questions to the parent, as the child cannot provide reliable information.
[b] Explain procedures in simple terms and speak directly to the child, while also involving the parent.
[c] Assume the child understands the purpose of all parts of the examination without explanation.
[d] Focus only on the physical aspects and ignore psychosocial development.
A nurse uses the HEADSS psychosocial assessment tool during an adolescent's health visit. What is the primary purpose of this tool?
[a] To assess for signs of physical abuse.
[b] To evaluate the adolescent's academic performance in school.
[c] To screen for high-risk behaviors by exploring Home, Education, Activities, Drugs, Sexuality, and Suicide/depression.
[d] To measure the adolescent's height, weight, and head circumference.
Tanner staging is a critical part of the adolescent health assessment. What does it evaluate?
[a] Cognitive development and problem-solving skills.
[b] The stage of moral reasoning according to Kohlberg's theory.
[c] The sequence of physical changes related to puberty and sexual maturation.
[d] The adolescent's relationship with their peer group.
A 16-year-old comes to the clinic alone. When beginning the health history, what is the nurse's most important action regarding confidentiality?
[a] To promise the adolescent that nothing will be shared with their parents, no matter what.
[b] To explain the clinic's policy on confidentiality and the specific limits, such as risk of harm to self or others.
[c] To refuse to see the adolescent without a parent or guardian present.
[d] To call the parents immediately to get permission for the assessment.
During the health assessment of a 45-year-old adult, the nurse should prioritize screening for which of the following?
[a] Childhood developmental milestones.
[b] Lifestyle-related risk factors such as hypertension, high cholesterol, and type 2 diabetes.
[c] Primitive reflexes like the Moro and Babinski reflex.
[d] Separation anxiety from their spouse or partner.
A nurse is performing an assessment on a pregnant woman at 28 weeks of gestation. The fundal height is measured at the level of the umbilicus. How should the nurse interpret this finding?
[a] The fundal height is appropriate for 28 weeks.
[b] The fundal height suggests the fetus is larger than expected for gestational age.
[c] The fundal height is less than expected, suggesting possible fetal growth restriction.
[d] This measurement is not a reliable indicator of fetal growth.
The nurse performs Leopold's maneuvers during an antenatal assessment. The primary purpose of this technique is to determine the:
[a] Gestational age of the fetus.
[b] Location of the fetal heart sounds.
[c] Adequacy of the maternal pelvis.
[d] Fetal lie, presentation, and position.
During an antenatal check-up, a nurse identifies the "classic triad" of pre-eclampsia symptoms, which are:
[a] Nausea, fatigue, and food cravings.
[b] Hypertension, proteinuria, and edema.
[c] Anemia, low blood sugar, and shortness of breath.
[d] Vaginal bleeding, abdominal cramping, and backache.
A nurse is performing a postnatal assessment on a woman who delivered 12 hours ago. Where should the nurse expect to palpate the uterine fundus?
[a] 4 cm below the umbilicus
[b] 2 cm above the symphysis pubis
[c] At the level of the umbilicus or 1 cm above
[d] The fundus should no longer be palpable abdominally.
When assessing a postnatal woman's lochia on day 3 postpartum, what would be a normal finding?
The acronym BUBBLE-HE is a guide for the postpartum assessment. What does the first 'B' stand for?
[a] Bowel
[b] Bladder
[c] Breasts
[d] Bonding
A nurse is conducting a health assessment on an 80-year-old client. A priority assessment should focus on:
[a] Tanner staging.
[b] Screening for childhood diseases.
[c] Functional status, fall risk, and polypharmacy.
[d] Plans for starting a new career.
When assessing an elderly client's ability to perform Activities of Daily Living (ADLs), what is the nurse evaluating?
[a] The ability to manage finances, shop, and cook.
[b] Basic self-care tasks such as bathing, dressing, toileting, and feeding.
[c] The client's ability to drive a car and use public transportation.
[d] The client's social network and community involvement.
A key component of a fall risk assessment for an elderly client includes:
[a] Asking if the client enjoys walking.
[b] Checking the client's blood type.
[c] Assessing gait and balance, reviewing medications, and checking for a history of falls.
[d] Measuring the client's waist-to-hip ratio.
During an assessment of a 2-year-old, the nurse observes the child playing with blocks and stacking them. This type of observation is most useful for assessing:
[a] Auditory acuity
[b] Fine motor skills and development
[c] Respiratory function
[d] Social interaction with peers
An adult male client tells the nurse he consumes about 5-6 alcoholic drinks every day after work. This information is a critical part of the assessment for:
[a] Nutritional status
[b] Sleep patterns
[c] Lifestyle and social history to identify health risks
[d] Occupational health hazards
When assessing a postnatal woman for diaphoresis and diuresis during the first few days after delivery, the nurse understands that this is:
[a] A sign of a developing postpartum infection.
[b] An abnormal finding requiring immediate medical intervention.
[c] A symptom of postpartum depression.
[d] A normal physiological process for the body to eliminate excess fluid accumulated during pregnancy.
A nurse assesses an elderly client and notes they are taking 12 different prescribed medications. This finding, known as polypharmacy, increases the client's risk for:
[a] Improved health outcomes.
[b] Adverse drug reactions, drug-drug interactions, and falls.
[c] Better medication adherence.
[d] A stronger immune system.
When assessing the emotional status of a new mother during a postnatal visit, the nurse should specifically screen for:
[a] Signs of elation and high energy.
[b] The mother's plans for future pregnancies.
[c] Symptoms of postpartum "blues," depression, and psychosis.
[d] The mother's level of satisfaction with the hospital stay.
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