Content Area: Developmental Stages NCLEX questions

A stillborn baby was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. The registered nurse is orienting a new nurse, and has provided education on how to communicate with the family. Which statement by the new nurse indicates that teaching has been effective? 1."How can I assist you with ways to remember your baby?" 2."You seem upset. Do you think a tranquilizer would help?" 3."I feel so bad. I don't understand why this happened either." 4."I can allow another 15 minutes together for you to grieve."

ans: 1 1."How can I assist you with ways to remember your baby?"

Which factors increase the risk for hypothermia in an older client? Select all that apply. 1.Burns 2.Anemia 3.Alcohol abuse 4.Hypoglycemia 5.Hyperthyroidism 6.Poor thermoregulation

ans: 1,2,3,4,6 1.Burns 2.Anemia 3.Alcohol abuse 4.Hypoglycemia 6.Poor thermoregulation

When administering a liquid medication to an uncooperative toddler, the nurse should implement which strategy? 1.Restrain the child in a high chair. 2.Allow the parents to remain in the room. 3.Restrain the child in a papoose-type device. 4.Remove the child to another room away from the parents.

ans: 2 2.Allow the parents to remain in the room. Allowing the parents to remain in the room will promote positive parent-child relationships as well as decrease the irrational fears that are so common in this age group.

The nurse is developing a plan of care for a school-age child who needs teaching related to the use of inhalers and peak flow meters. What is the best expected outcome to be included in the plan of care for this child? 1.The child denies shortness of breath or difficulty breathing. 2.The child has regular respirations at a rate of 18 to 22 breaths per minute. 3.The child watches the educational video and reads printed information provided. 4.The child expresses feelings of mastery and competence with the breathing devices.

ans: 4 4.The child expresses feelings of mastery and competence with the breathing devices. School-age children strive for mastery and competence to achieve the developmental task of industry and accomplishment. Assessment data do not relate to the child needing teaching. Although reading and watching may be components of the teaching-learning process, they are passive processes. Expressing feelings of mastery and competence with the breathing devices indicates that learning took place.

The nurse is preparing to administer an intramuscular injection to a 11-month-old child. Which location should the nurse select to administer the medication? 1.Deltoid muscle 2.Dorsogluteal muscle 3.Ventrogluteal muscle 4.Vastus lateralis muscle

ans: 4 Vastus lateralis muscle The vastus lateralis muscle is the best choice for intramuscular injections for all age groups and should always be used in children younger than 3 years, and the ventrogluteal muscle is safe for children older than 18 months, because it is free of major blood vessels and nerves.

An older client tells the home care nurse that she has occasional urgency and frequent stress incontinence. What should be the nurse's determination, based on this information? 1.Follow-up medical care is necessary. 2.This is a normal physiological sign of aging. 3.This finding is caused by stress on the bladder. 4.A bladder-training program is necessary for the client.

ans: 1 1.Follow-up medical care is necessary. Occasionally women experience stress incontinence associated with aging, which is often a result of decreased perineal tone. However, this is not a sign of aging. Thus, options 2 and 3 are incorrect. Follow-up medical care is necessary. Bladder training is premature without further assessment and workup with the primary care provider.

The nurse is assessing a 36-month-old child during a wellness visit to the pediatrician. The child weighs 43 pounds and is 41 inches tall. After plotting the measurements on the standardized growth charts for a 36-month-old child, and evaluating the curve from birth to this appointment, what should the nurse do next? 1.Assess the parents' body shape and stature. 2.Document these as expected findings for a 3-year-old child. 3.Counsel the parent on appropriate physical activities and exercises. 4.Refer the child and the parents for nutritional counseling related to obesity.

ans: 1 Assess the parents' body shape and stature.v

The nurse of a well-baby clinic is assessing the language and communication developmental milestones of a 2-month-old infant. The nurse anticipates which milestone to begin to occur in the infant at this developmental age? 1.Cooing sounds 2.Use of gestures 3.Babbling sounds 4.Increased interest in sounds

ans: 1 Cooing sounds Between the ages of 1 and 3 months, the infant will produce cooing sounds. Babbling sounds are common between the ages of 3 and 4 months. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months.

The nurse is teaching a group of nursing students about normal and expected age-related changes of the ear of the older adult. The nurse knows that there is a need for additional teaching if a student indicates that which are normal and expected changes? Select all that apply. 1.Vertigo 2.Unilateral deafness 3.Development of tinnitus 4.Hardening of the stapes 5.Alteration in hearing capacity

ans: 1,2,3,4 Vertigo Unilateral deafness Development of tinnitus Hardening of the stapes

The nurse is caring for a client who has just died. What end-of-life information needs to be documented in the client's medical record? Select all that apply. 1.Time and date of death 2.Time of body transfer and destination 3.Family members present at the time of death 4.Name of health care provider certifying death 5.Medical tubes, devices, or lines left in the body

ans: 1,2,4,5 1.Time and date of death 2.Time of body transfer and destination 4.Name of health care provider certifying death 5.Medical tubes, devices, or lines left in the body Documentation of present family members is not required.

The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings should indicate to the nurse that death is imminent? Select all that apply. 1.Dyspnea 2.Cyanosis 3.Tachypnea 4.Kussmaul's respiration 5.Irregular respiratory pattern 6.Adventitious bubbling lung sounds

ans: 1,2,5,6 dyspnea cyanosis irregular respiratory pattern adventitious bubbling lung sounds Respiratory assessment findings that indicate death is imminent include poor gas exchange as evidenced by hypoxia, dyspnea, or cyanosis; altered patterns of respiration, such as slow, labored, irregular, or Cheyne-Stokes pattern (alternating periods of apnea and deep, rapid breathing); increased respiratory secretions and adventitious bubbling lung sounds (death rattle); and irritation of the tracheobronchial airway as evidenced by hiccups, chest pain, fatigue, or exhaustion. Kussmaul's respirations are abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis. Tachypnea is defined as rapid breathing. In an adult, it would indicate a respiratory rate of over 20 breaths per minute.

The nurse is conducting a teaching session on skin changes in the gerontological population. Which, if stated by a student, indicates a need for further teaching? Select all that apply. 1.Increased blood supply 2.Decreased subcutaneous fat 3.Increased extracellular water 4.Increased immunocompetence 5.Decreased activity of sebaceous glands

ans: 1,3,4 Increased blood supply Increased extracellular water Increased immunocompetence Skin changes associated with the gerontological population include decreased blood supply, decreased subcutaneous fat, decreased extracellular water, decreased immunocompetence, and decreased activity of sebaceous glands.

The nurse is caring for a client at the end of life. The client is withdrawn and agitated and is experiencing visual hallucinations. What actions should the nurse take to provide end-of-life psychological care? Select all that apply. 1.Provide privacy to the client and family. 2.Speak in a soft tone, but not directly to the client. 3.Encourage the family to talk with and reassure the client. 4.Encourage visits by appropriate spiritual services as desired. 5.Encourage family and visitors to keep conversation to a minimum to provide a calming environment.

ans: 1,3,4 Provide privacy to the client and family. 3.Encourage the family to talk with and reassure the client. 4.Encourage visits by appropriate spiritual services as desired.

The nurse is reviewing general injury prevention guidelines with the pediatric department staff in the hospital. Which interventions aimed at promoting safety specifically for infants and toddlers should the nurse include in this review? Select all that apply. 1.Ensure that crib sides are up. 2.Place large, soft pillows in the crib. 3.Use large, soft toys without small parts. 4.Attach a pacifier to a stretchable piece of ribbon and pin to the infant's clothing. 5.Allow a toddler who is toilet training privacy in the bathroom to promote autonomy. 6.Ensure that an infant or toddler is never left unattended while lying on a changing table.

ans: 1,3,6 1.Ensure that crib sides are up. 3.Use large, soft toys without small parts. 6.Ensure that an infant or toddler is never left unattended while lying on a changing table.

The nurse working in a long-term care facility is performing an admission assessment on an older client. The client states that she uses antioxidant therapy to reverse the effects of aging. The nurse should incorporate which information when planning a response to this client? Select all that apply. 1.High doses of antioxidants can be harmful to the body. 2.It has been proven that antioxidants are highly effective. 3.High doses of antioxidants are very beneficial to the body. 4.Antioxidant therapy consists of a variety of vitamins and minerals. 5.It is necessary to discuss this therapy with the primary health care provider before starting it.

ans: 1,4,5 High doses of antioxidants can be harmful to the body. Antioxidant therapy consists of a variety of vitamins and minerals. It is necessary to discuss this therapy with the primary health care provider before starting it.

A 4-year-old child who was recently hospitalized is brought to the clinic by his mother for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed ever since he was brought home from the hospital. The mother is concerned and asks the nurse what to do. Which is the appropriate nursing response? 1."You need to discipline the child." 2."This is a normal occurrence after hospitalization." 3."The child probably has developed a urinary tract infection." 4."We will need to discuss this behavior with the pediatrician."

ans: 2 2."This is a normal occurrence after hospitalization." Regression can occur in a preschooler, and it is most often a result of the stress of the hospitalization.

A 9-year-old child is hospitalized in traction for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development? 1.Providing a music player 2.Tutoring to keep the child up with schoolwork 3.Providing a phone for calling family and friends 4.Placing computer games, a television, and videos at the bedside

ans: 2 Tutoring to keep the child up with schoolwork

The nurse is preparing to administer an immunization to an 11-year-old child. Which site should the nurse select as the best area to administer the intramuscular injection? 1.Deltoid muscle 2.Ventral gluteal muscle 3.Anterolateral aspect of the thigh 4.Posterior lateral aspect of the thigh

ans: 2 ventral gluteal muscle he ventral gluteal site may be used for intramuscular injections in older children. In children who have not yet developed the gluteal muscle (those younger than 2 years of age), the preferred site for intramuscular injections is the anterolateral aspect of the thigh. The deltoid muscle can be used in children 18 months or older; however, in an 11-year-old child, the ventral gluteal muscle is the preferred site.

The nurse is caring for an 8-year-old child in the late stage of a terminal illness. The child is semiconscious. The nurse notices that the child has a dry mouth, and the family believes that the child is thirsty. The family is attempting to give the child a large glass of apple juice. What action should the nurse take? Select all that apply. 1.Give the child the glass of apple juice. 2.Perform frequent oral care with mouth swabs. 3.Give the child small sips of water or ice chips if alert. 4.Provide the child with mouthwash to help with mouth odor. 5.Inform the family that oral intake increases as death approaches. 6.Encourage the family to participate in oral care as much as desired.

ans: 2,3, 6 Perform frequent oral care with mouth swabs. Give the child small sips of water or ice chips if alert. Encourage the family to participate in oral care as much as desired.

A mother of a 3-year-old child asks the nurse what personal and social developmental milestones she can expect to see in her child. The nurse should tell the mother to expect which findings? Select all that apply. 1.Begins problem-solving 2.Exhibits sexual curiosity 3.May begin to masturbate 4.Notices gender differences 5.Develops a sense of initiative 6.Develops positive self-esteem through skill acquisition

ans: 2,3,4 Exhibits sexual curiosity May begin to masturbate Notices gender differences Personal and social developmental milestones of the 3-year-old include exhibiting sexual curiosity; possibly beginning to masturbate; noticing gender differences and identifying with children of like gender; putting on articles of clothing; brushing teeth with help; washing and drying hands using soap and water; knowing own name; and understanding the need to take turns and share with others, but perhaps not being ready to do so. Developmental milestones for the 4- and 5-year-old child include developing a sense of initiative and beginning to problem-solve. Developing positive self-esteem through skill acquisition and task completion is characteristic of a 6- to 8-year-old child.

The nurse is providing postmortem care to an assigned client. Which actions are appropriate in the provision of postmortem care? Select all that apply. 1.Remove dentures and glasses. 2.Note if any specimens need to be collected. 3.Apply identifying tags to the body per agency policy. 4.Remove all equipment, tubes, and indwelling lines as prescribed. 5.Ask the family to wait in the waiting room while the body is prepared.

ans: 2,3,4 Note if any specimens need to be collected. Apply identifying tags to the body per agency policy. Remove all equipment, tubes, and indwelling lines as prescribed.

he nurse is caring for a client at the end of life. What late cardiovascular and respiratory findings should the nurse expect to note during the assessment? Select all that apply. 1.Friction rub 2.Irregular heart rate 3.Decreased pulse rate 4.Decreased blood pressure 5.Irregular breathing patterns

ans: 2,3,4,5 Irregular heart rate Decreased pulse rate Decreased blood pressure Irregular breathing patterns The heart is one of the main organs for perfusion and the lungs are the main organ for gas exchange. When death nears, the pulse will first increase and then decrease and weaken. The heart will beat irregularly, causing a decrease in blood pressure.

he nurse is performing an assessment on an older client. Which signs/symptoms are age-related changes in the eye? Select all that apply. 1.Clear sclera 2.Blurred vision 3.Protruding cornea 4.Increased tear production 5.Diminished pupillary adaptation to darkness 6.Increased ability to discriminate among colors

ans: 2,5 blurred vision diminished pupillary adaptation to darkness ge-related changes in the eye include flattening of the cornea, which causes blurred vision; poor pupillary adaptation to darkness; yellowing sclera; a sunken appearance; diminished tear production; diminished ability to discriminate among colors; and reduced ocular muscle strength.

The nurse is caring for a hospitalized adolescent who is on respiratory isolation precautions. The nurse is preparing a plan of care and provides the adolescent with which appropriate age-related activity? 1.A puzzle 2.Finger paints 3.A computer iPad 4.Drawing materials

ans: 3 3.A computer iPad Age-related activities for adolescents include sports, videos, movies, reading, parties, hobbies, a computer iPad, and experimenting with makeup and hairstyles. The remaining options are most appropriate for the preschooler.

A 16-year-old adolescent with a 10-year history of type 1 diabetes mellitus comes into the primary health care provider's office for a sports physical examination. In looking at the record, the nurse identifies that the adolescent had four hyperglycemic reactions in the past year. In assessing the causes of these reactions, which nursing action is most appropriate? 1.Ask the mother what time of day the hyperglycemic reactions occur. 2.Complete the basic preparation for a physical and discuss sports with the adolescent. 3.Ask the mother to step outside, and discuss the hyperglycemic reactions with the adolescent. 4.Complete the basic preparation for the physical before the primary health care provider arrives.

ans: 3 Ask the mother to step outside, and discuss the hyperglycemic reactions with the adolescent. Based on the age and developmental level of the adolescent, the best action to assess the causes of these reactions is to discuss their occurrences with the 16-year-old in private

When giving an intramuscular injection to a 4-year-old child, which technique is best for the nurse to use? 1.Use the vastus lateralis muscle only. 2.Distract the child with conversation or a toy. 3.Obtain assistance to administer the injection. 4.Allow the child to choose between a lying or standing position.

ans: 3 Obtain assistance to administer the injection.

The pediatric nurse is caring for a hospitalized preschooler who is in traction. Which play activity should the nurse implement with this child? 1.Listening to music 2.Hand sewing a picture 3.Coloring book and crayons 4.Reading from a large picture book

ans: 3 coloring book and crayons In the preschooler, play is simple, imaginative, and creative, and dramatic play is prominent. The preschooler likes to build and create things. The preschooler likes dress-up clothes, paints, paper, and crayons for creative expression.

A client in the emergency department has died following a traumatic accident. The nurse notes that the family is in crisis and expressing difficulty managing this sudden, unexpected death. What actions would be the most appropriate for the nurse to take in order to help the family? Select all that apply. 1.Contact the forensic nurse examiner. 2.Avoid eye contact with the family of the client. 3.Place the client in a private room to allow grieving. 4.Call the psychiatric crisis nurse team to assist the family. 5.Request that the family leave the emergency department to avoid disturbing other clients.

ans: 3, 4 Place the client in a private room to allow grieving. Call the psychiatric crisis nurse team to assist the family.

The nurse in a well-baby clinic is providing safety instructions to the mother of a 1-month-old infant. Which safety instructions are most appropriate to include at this age? Select all that apply. 1.Lock up all poisons. 2.Cover electrical outlets. 3.Never shake the infant's head. 4.Place the infant on the back to sleep. 5.Remove hazardous objects from low places.

ans: 3,4 Never shake the infant's head. Place the infant on the back to sleep.

The nurse is caring for a client at the end of life. What skin changes should the nurse expect to note on assessment? Select all that apply. 1.Dry skin 2.Warm skin 3.Waxlike texture 4.Mottling of hands, arms, feet, and legs 5.Cyanosis of the nose, nail beds, and knees

ans: 3,4,5 Waxlike texture Mottling of hands, arms, feet, and legs Cyanosis of the nose, nail beds, and knees At the end of life, the skin loses elasticity, and, therefore, a waxlike texture is noted. Decreased perfusion will cause mottling and cyanosis of the skin, nose, and nail beds. The skin will become cool and clammy as death approaches, not warm or dry.

The nurse assesses for which early sign to detect pneumonia in an older client on bed rest? 1.Poor skin turgor 2.Blood-tinged sputum 3.Diminished respiratory rate 4.Rectal temperature of 100.2° F (37.8° C)

ans: 4 4.Rectal temperature of 100.2° F (37.8° C) Older clients may not present with the usual signs and symptoms of illness. Because of their lower-than-normal body temperature, an early sign of fever would be a temperature of 99° F (37.2° C) rectally. Poor skin turgor is a sign of dehydration. Blood-tinged sputum could be a sign of heart failure. In later stages of pneumonia, the respiratory rate increases in an attempt to compensate for poor oxygen exchange.

The nurse diligently reminds an older client to perform deep-breathing and coughing exercises as a preventative measure for developing respiratory problems, keeping in mind that which normal age-related change places the client at risk for respiratory infections? 1.Alveolar membrane thins. 2.Alveolar walls are destroyed. 3.Lung tissue becomes less elastic and less rigid. 4.Reduced ciliary movement creates ineffective cough.

ans: 4 4.Reduced ciliary movement creates ineffective cough. As aging occurs, ciliary movement is reduced, alveolar membranes thicken (not thin), and lung tissue becomes less elastic and more rigid (not less rigid). Destruction of alveolar walls is a characteristic of chronic obstructive pulmonary disease and is not a normal age-related change found in the older client.

The community health nurse is preparing a presentation to an older adult group on expected and normal changes of aging. Which expected and normal changes of the renal system should the nurse include in the presentation? Select all that apply. 1.Urinary incontinence 2.Urinary tract infection 3.Progressive renal failure 4.Elevated blood urea nitrogen 5.Decreased glomerular filtration rate

ans: 4,5 4.Elevated blood urea nitrogen 5.Decreased glomerular filtration rate The normal blood urea nitrogen level changes with age, and elevates above normal. This occurs as a result of a decreased glomerular filtration rate, which is a normal and expected finding occurring with age. Urinary incontinence is not a normal age-related change and usually occurs as a result of another pathophysiological process. A urinary tract infection, although more common among older adults, is not considered to be normal. Progressive renal failure is also more common among older adults but is an abnormal pathophysiological process.

The nurse understands that which neurological changes are expected and normal age-related changes of the older adult? Select all that apply. 1.Confusion 2.Unilateral tremors 3.Personality changes 4.Delayed motor responses 5.Declining short-term memory recall

ans: 4,5 delayed motor responses declining short term memory recall Motor responses are normally delayed, and short-term memory recall decline occurs in the older adult because of the normal reduction in the size and weight of the brain. Confusion and personality changes, however, are associated with dementia, which is an abnormal finding. Unilateral tremors are associated with the development of Parkinson's disease, which is an abnormal pathophysiological process.

A 7-year-old child is hospitalized with a fracture of the femur and placed in traction. Which appropriate play activity should the nurse select to help meet the growth and development needs of the child? 1.A board game 2.A large puzzle 3.A finger-painting set 4.A coloring book with crayons

ans: A a board game The school-age child becomes organized with more direction with play activities. Such activities include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television. A puzzle is most appropriate for a toddler, Finger painting and coloring are most appropriate for a preschooler.