Peds Test 1
The nurse is providing teaching to parents regarding developmental milestones that should be expected by the end of the eighth month of infancy. The nurse determines that the parents understand this teaching when they correctly identify which milestone? (Select all that apply.) A. Plays peek-a-boo B. Transfers objects from hand to hand C. Begins using the pincer grasp D. Stands without assistance E. Sits alone without assistance
B. Transfers objects from hand to hand C. Begins using the pincer grasp E. Sits alone without assistance Rationale: By the end of the eighth month, the infant should be able to: transfer objects from hand to hand, sit alone without assistance, and begin using the pincer grasp. Standing without assistance and playing peek-a-boo is expected between 10 to 12 months.
The nurse is developing a plan of care for a client diagnosed with autism spectrum disorder (ASD). Which nursing diagnosis is most appropriate for the nurse to include? A. Macrocephaly, Risk for B. Airway Clearance, Ineffective C. Communication: Verbal, Impaired D. Infection, Risk for
C. Communication: Verbal, Impaired Rationale: Communication: Verbal, Impaired is an appropriate nursing diagnosis for a client with ASD. Macrocephaly, Risk for is not a nursing diagnosis. The client with ASD is not at risk for infection or ineffective airway clearance. (NANDA-I ©2014)
The mother of an 8-month-old infant is concerned that her infant, who weighed 8 pounds at birth, is now 18 pounds. The mother asks, "I'm afraid my baby is overweight for her age." How should the nurse respond? A. "Your child may be slightly underweight, and you should consult with a nutritionist." B. "At this stage, a child requires a more limited food intake, so your child's weight gain should stabilize." C. "You are correct. Your child is at risk for obesity, and you should consult with a nutritionist." D. "Your child's growth is on target because a baby's birth weight triples in the first year."
D. "Your child's growth is on target because a baby's birth weight triples in the first year." Rationale: The child's growth is on target. An infant's birth weight doubles by about 5 months and triples in the first year. The child is not underweight, is not at risk for obesity, and does not require limited food intake.
A child is newly diagnosed with cerebral palsy (CP). For which type of cerebral palsy should the nurse most likely plan care? A. Mixed cerebral palsy B. Ataxic cerebral palsy C. Spastic cerebral palsy D. Dyskinetic cerebral palsy
C. Spastic cerebral palsy Rationale: About 80% of all cases of CP are classified as spastic. The other types of cerebral palsy are less common.
The nurse is assessing an infant's growth and development. Which assessment finding is specific to the infant stage of growth and development? A. Growth is associated with type and quality of feeding. B. Jaw proportions change. C. Most growth takes place in long bones. D. The child requires a more limited food intake.
A. Growth is associated with type and quality of feeding. Rationale: In the infant stage of development, growth is associated with type and quality of feeding. Toddlers, not infants, require less food intake. Most growth occurs in long bones in preschool-age children, not in infants. Jaw proportion changes do not occur during infancy.
The nurse is teaching parents about the temperament theory. Which characteristic of this theory should the nurse include? (Select all that apply.) A. The "easy" child B. The "mean" child C. The "hyperactive" child D. The "slow-to-warm-up" child E. The "difficult" child
A. The "easy" child D. The "slow-to-warm-up" child E. The "difficult" child Rationale: The "easy" child, "difficult" child, and "slow-to-warm-up" child are all characteristics of the temperament theory. The "mean" child and "hyperactive" child are not terms that are associated with the temperament theory.
A client brings in her infant and states "I think he is ready to switch to solid foods." The baby's birth weight has doubled since birth, can maintain balance when stood up, and opens their mouth to indicate desire for food. Which response by the nurse is appropriate? A. "Your baby is on target with developmental goals. Let's talk about the process of switching to solid food." B. "Unfortunately, your baby is behind on their development, and solid foods is not appropriate at this time." C. "You should ask your doctor to see what he thinks." D. "Let me get some carrots and we'll try it out right now."
A. "Your baby is on target with developmental goals. Let's talk about the process of switching to solid food." This baby is on target based on the developmental milestones, and it would be appropriate to start feeding the child solid foods, introducing one food at a time, to see how the child tolerates it.
The nurse is caring for her friend's child while she runs out to grab groceries. While she is gone, the nurse notices the child has not attempted to walk yet. The nurse knows the ability to walk should be accomplished by how many month(s) of age? A. 10-12 months B. 1 month C. 6-8 months D. 18 months
A. 10-12 months An infant should be able to walk holding onto furniture by 10-12 months of age.
The nurse assesses a child suspected of having autism spectrum disorder (ASD). Which behavior noted in the assessment supports the diagnosis? (Select all that apply.) A. An aversion to being touched B. Echolalia C. Emotional calm D. Stereotypy E. Deep set eyes
A. An aversion to being touched B. Echolalia D. Stereotypy Rationale: Behaviors indicative of ASD include stereotypy (rigid and obsessive behavior), echolalia (the compulsive parroting of a word or phrase just stated by another), and an aversion to being touched. Emotional lability (rapid, significant mood changes), not emotional calm, is a clinical manifestation of ASD. ASD does not manifest in any physical signs.
The nurse in a pediatric clinic notices a 3-year-old continues to poke their rectum with their finger. According to Freud, what stage of personality development is this child in? A. Anal Stage B. Latency Stage C. Genital Stage D. Touching Stage
A. Anal Stage This child is in the anal stage of development where there is increased interest by the child on the anal region. The latency stage is 6-12 years and elaborates on previously acquired traits from the phallic, anal, and oral stages. The genital stage is >12 years and begins at puberty and ends at the maturation of the reproductive system
When assessing a child with down syndrome, the nurse should understand that children with this genetic defect are at high risk for: A. Cardiac issues B. Liver issues C. Increased fertility D. Abnormally High IQs
A. Cardiac issues 40-45% of all children born with down syndrome will have a heart defect. The most common are ASD and VSD. They can also be born with a patent foramen ovale which allows blood to flow from the right atrium to the left atrium and mixes arterial and venous blood.
Which intervention is an appropriate nonpharmacologic treatment for the nurse to include in the plan of care for a client with autism spectrum disorder (ASD)? (Select all that apply.) A. Creating an environment that is conducive to positive behavior management B. Promoting enhanced communication C. Teaching the family about studies on complementary care D. Encouraging parents not to vaccinate their children E. Establishing support for the parents and family
A. Creating an environment that is conducive to positive behavior management B. Promoting enhanced communication C. Teaching the family about studies on complementary care E. Establishing support for the parents and family Rationale: Children with ASD will benefit from the following nonpharmacologic treatment options: establishing support for the parents and family; creating an environment that is conducive to positive behavior management; promoting enhanced communication; and educating the family about studies on the use of complementary care. Discouraging parents from vaccinating their children is not an appropriate treatment option for children with ASD.
A student nurse notices a client is prescribed botox for CP. The nurse knows the use of this drug in this case is to: A. Decrease muscle spasticity B. Tighten up their wrinkles C. There is no clinical use for botox on CP patients D. Cure their vision problems
A. Decrease muscle spasticity Botox is used in CP patients to decrease muscle spasticity. Vision problems are a side effect of the medication.
Which screening assessment should the nurse use for a child demonstrating developmental delays associated with cerebral palsy (CP)? (Select all that apply.) A. Diaper pull B. Phalen test C. Babinski reflex D. Heel-shin test E. Head turn
A. Diaper pull E. Head turn Rationale: All infants who show symptoms of developmental delay should be evaluated by using two simple screening assessments. The first is a diaper pull, which is conducted by placing a clean diaper on the child's face; the infant with CP will use one hand or will not remove the cloth at all. The other test is the head turn, which is conducted by turning the infant's head to one side; if the child has a persistent asymmetric tonic neck reflex beyond 6 months of age, this indicates a pathologic condition. The Babinski reflex does not indicate the presence or absence of CP. The Phalen test is used to assess for carpal tunnel syndrome. The heel-shin test is used with adults to determine nervous system integrity of the lower extremities.
The nurse admitting a child who is suspected of having autism spectrum disorder (ASD) knows that it is necessary to rule out medical causes for the child's behavior before diagnosing ASD. Which diagnostic test should the nurse anticipate will be ordered for the client? (Select all that apply.) A. Electroencephalography B. ABG C. DNA analysis D. CT scan E. KUB x-ray
A. Electroencephalography C. DNA analysis D. CT scan Rationale: To rule out medical causes for behavior in a suspected ASD client, the healthcare provider should order a CT scan or MRI, DNA analysis, lead screening, and electroencephalography. A KUB x-ray is a radiograph of the kidneys, ureters, and bladder. ABGs are arterial blood gases and are used to measure the amounts of oxygen and carbon dioxide in the blood. They are not used to rule out ASD.
The nurse is caring for a client with cerebral palsy (CP) who wears bilateral leg braces and requires full assistance to mobilize. For which condition is the client at risk? (Select all that apply.) A. Fatigue B. Pressure injuries C. Muscle contractures D. Atherosclerosis E. Increased dental caries
A. Fatigue B. Pressure injuries C. Muscle contractures Rationale: The nurse should protect bony prominences and assess regularly for redness and skin breakdown under the braces. The client's inability to change positions independently also places her at risk for pressure wounds and muscle contractures. Fatigue results from the extended energy needed to work against the muscle contractures. Atherosclerosis is a severe problem with CP that is associated with aging but is not caused by the leg braces or immobility. Dental caries are also unrelated to the braces or physical dependence.
The nurse is reviewing the medical record of a 6-year-old client diagnosed with autism spectrum disorder (ASD). Which item in the health history should the nurse consider may have been a factor in the client developing ASD? A. Fetal alcohol syndrome B. Appropriate adaptation to new environments C. Postterm birth D. Childhood vaccinations
A. Fetal alcohol syndrome Rationale: The ingestion of alcohol, tobacco, and toxic substances has been known to cause birth defects. Therefore, fetal alcohol syndrome could possibly be a factor in the development of ASD. Childhood vaccinations have not been proven to cause ASD. Appropriate adaptation to new environments and postterm birth have no link to ASD.
The nurse is assessing an infant brought into a clinic for a routine evaluation. What fine motor skills should she look for on an infant <1 month? (Select all that apply) A. Forms hand into a fist B. Looks at and plays with own fingers C. Holds rattle when placed in hand D. Draws arms and legs to body when crying E. Follows objects in line of vision
A. Forms hand into a fist D. Draws arms and legs to body when crying Forms hands into a fist and draws arms/legs to body when crying are both normal fine motor development for an infant <1 month. Holds rattle and looks at/plays with fingers are fine motor development of a 2-4 month old. Follows onjects in line of vision is a sensory function, not motor.
The nurse is teaching a parent group about growth and development. Which factor should the nurse include in explaining how culture and/or ethnicity can influence growth and development? (Select all that apply.) A. Genetic variations B. Nutritional practices C. Temperamental characteristics D. Social interaction patterns E. Identity establishment
A. Genetic variations B. Nutritional practices D. Social interaction patterns Rationale: Social interaction patterns, genetic variations, and nutritional practices of various cultural or ethnic groups can influence growth and development. Identity establishment and temperamental characteristics are not cultural or ethnic influences on growth and development.
The nurse is teaching the parents of a child recently diagnosed with autism spectrum disorder (ASD). Which etiologies should the nurse include? (Select all that apply.) A. Genetics B. Neurotransmitters C. Environmental factors D. Mercury-containing vaccinations E. Immunologic factors
A. Genetics B. Neurotransmitters C. Environmental factors E. Immunologic factors Rationale: The etiology of ASD is uncertain, but it is believed to be the result of an intricate co-action between genetic, immunologic, and environmental circumstances. There is research being conducted on the role of neurotransmitters, such as dopamine and serotonin. There is no evidence that mercury-containing vaccinations cause autism.
The nurse is helping develop a safety plan with the parents of a nonverbal, school-aged child. Which information is most appropriate for the nurse to include in the plan? (Select all that apply.) A. Have the child demonstrate how to dial 911 in case of an emergency. B. Advise the family to notify the local emergency dispatch center that a client with special needs lives there. C. Advise the family to notify the local hospital and clinic that a client with special needs lives there. D. Have the parents demonstrate how to dial 911 in case of an emergency. E. Assist the family in finding adaptive equipment the child can use to participate in different activities.
A. Have the child demonstrate how to dial 911 in case of an emergency. B. Advise the family to notify the local emergency dispatch center that a client with special needs lives there. E. Assist the family in finding adaptive equipment the child can use to participate in different activities. Rationale: It is important for the parents to notify the local emergency dispatch that a person with special needs lives at that number. In case of an emergency, the personnel who respond will be able to interact appropriately with the client. Adaptive equipment is important for a person with special needs to be able to participate in different activities safely. It is not necessary to contact the local hospital and clinic if the dispatch has already been notified. It is important that the nonverbal client, not the parents, can demonstrate dialing 911 or other emergency numbers, in case the client must do so in an emergency.
The nurse is conducting an educational session for the staff about failure to thrive (FTT). Which type of family should the nurse identify as being at risk for this health problem? (Select all that apply.) A. History of depression B. Experience mental retardation C. Low-income D. Abuse substances E. Single-parent
A. History of depression B. Experience mental retardation C. Low-income D. Abuse substances Rationale: Parents or caregivers who use substances or who have experienced depression or mental retardation are more likely to place a child at risk for FTT. Children living in poverty are also at risk for FTT. A single-parent home is not a factor in failure to thrive.
The nurse is preparing a teaching tool for the staff at an assisted living facility. Which statement should the nurse use to describe geriatric failure to thrive (GFTT)? A. It is a disorder of undernutrition in an older adult. B. There is no disorder called geriatric failure to thrive. C. Older adults are less active and require less caloric intake. D. It is part of the normal aging process.
A. It is a disorder of undernutrition in an older adult. Rationale: Failure to thrive can affect any age group. Geriatric failure to thrive is a true undernutrition disorder. This health problem is not a normal part of the aging process. It is not caused by inactivity and the need for less caloric intake.
While conducting a home visit, the nurse observes a new mother heat the water to the proper temperature, place the infant in a sink for a morning bath, and then walk away to collect towels and soap. Which topic should the nurse use to guide teaching for this mother? A. Knowledge deficit B. Risk for developmental delays C. Risk for coping issues D. Thermoregulation issue
A. Knowledge deficit Rationale: The mother may not be aware that the baby can drown in a sink full of water, so the topic of knowledge deficit is correct. The nurse would need to teach the mother about water safety for the infant. Nothing indicates the infant is having thermoregulation issues, so this topic would not be applicable at this time. Neither the mother nor the infant has sustained a head injury, so the risk for developmental delays is not applicable at this time. There is no evidence to suggest that the mother is at risk for coping issues.
Which medication should the nurse expect to find on the medication administration record (MAR) for a child with autism spectrum disorder (ASD)? (Select all that apply.) A. Mood stabilizer B. Selective serotonin reuptake inhibitor (SSRI) C. Beta blocker D. Angiotensin-converting enzyme (ACE) inhibitor E. Stimulant
A. Mood stabilizer B. Selective serotonin reuptake inhibitor (SSRI) E. Stimulant Rationale: While there is no medication to cure ASD, medications are prescribed to manage behaviors and symptoms. These medications include stimulants, SSRIs, and mood stabilizers. ACE inhibitors and beta blockers are used to treat hypertension.
The nurse is preparing teaching material for the parents of a child with cerebral palsy (CP). Which treatment should the nurse include in this teaching? (Select all that apply.) A. Muscle relaxants B. Surgery C. Positioning devices D. Serial casting E. A low-calorie diet
A. Muscle relaxants B. Surgery C. Positioning devices D. Serial casting Rationale: Muscle relaxants may help the child with spasticity often associated with CP. Surgery may be helpful for children who experience contractures as a result of CP. Serial casting may be helpful for children with CP. Positioning devices are used to prevent contractures. A low-calorie diet is not recommended for children with CP.
The nurse is planning care for a newborn with a cleft palate. For which health problem should the nurse plan interventions for this client? A. Organic failure to thrive (OFTT) B. Nonorganic failure to thrive (NFTT) C. Sleep deprivation D. Colic
A. Organic failure to thrive (OFTT) Rationale: Cleft palate can cause OFTT. Causes of NFTT include lack of mothering, insufficient stimulation, and inadequate nutritional intake. Colic and sleep deprivation are not directly associated with a cleft palate.
During an assessment, the nurse suspects that an 18-month-old client is demonstrating manifestations of cerebral palsy (CP). Which assessment finding should the nurse use to validate this conclusion? (Select all that apply.) A. Poor trunk control B. Arched back C. Thumb sucking D. Head lag E. Asymmetric crawling
A. Poor trunk control B. Arched back D. Head lag E. Asymmetric crawling Rationale: Abnormalities that can be assessed that indicate cerebral palsy include asymmetric crawling, head lag, arched back, and poor trunk control. Thumb sucking is not a manifestation of CP.
The nurse is preparing teaching for an adolescent client who has a newly prescribed medicine. Which factor/information should the nurse consider when providing information to the client? (Select all that apply.) A. Possible side effects B. Physical development of the client C. Compliance requirements D. Cognitive level of the client E. Physical therapy requirements
A. Possible side effects B. Physical development of the client C. Compliance requirements D. Cognitive level of the client Rationale: In addition to prescription instructions regarding compliance and side effects, it is important for the nurse to consider the physical and cognitive development of the client. Most adolescents have reached a stage in physical development that they may be able to take an adult dosage. The cognitive development of these clients is also very broad, and if necessary the nurse should enlist the help of the parent or guardian. Physical therapy requirements do not need to be a consideration at this time.
The nurse is conducting a consultation with a client who has a developmental alteration. Which factor should the nurse consider when interacting with the client? (Select all that apply.) A. Preferred learning method B. Literacy skills C. Family history D. Developmental level E. Reliance on social services
A. Preferred learning method B. Literacy skills D. Developmental level Rationale: When interacting with a client who has a developmental alteration, the nurse should consider the client's developmental level, literacy skills, and preferred learning method. The client's family history and reliance on social services are not related to interactions with the client.
A small-for-gestational age neonate is showing signs of poor development. Which factor should the nurse identify that increases this client's risk of cerebral palsy (CP) before or during birth? (Select all that apply.) A. Premature birth B. Injury to the cerebral cortex C. Hyperbilirubinemia D. Fetal viral infection E. Neonatal sepsis
A. Premature birth B. Injury to the cerebral cortex D. Fetal viral infection Rationale: Most cases of CP are caused before or during birth by a brain insult; this includes premature birth, fetal viral infection, and injury to the cerebral cortex. CP can also develop after birth to age 2 years, when it can be caused by neonatal sepsis and hyperbilirubinemia.
The nurse is providing care to a pregnant client. Which teaching should the nurse provide to the client to reduce the potential risk of developmental alterations in the baby? (Select all that apply.) A. Prescription and nonprescription medication use B. Adequate proximodistal growth C. Psychosocial developmental milestones D. Nutrition E. Avoidance of harmful substances
A. Prescription and nonprescription medication use D. Nutrition E. Avoidance of harmful substances Rationale: Some developmental delays can be avoided through prenatal client teaching on nutrition, avoiding harmful substances, and the proper use of prescription and nonprescription medications. Information on psychosocial developmental milestones and proximodistal growth are not appropriate at this time.
Which assessment finding should the nurse expect in a child with autism spectrum disorder (ASD)? (Select all that apply.) A. Reiteration of questions as opposed to answering them B. Echolalia C. Stuttering D. Use of the word you to represent I E. Enchantment with rhythmic repetition of verse or song
A. Reiteration of questions as opposed to answering them B. Echolalia D. Use of the word you to represent I E. Enchantment with rhythmic repetition of verse or song Rationale: Echolalia (parroting a particular word or phrase), repetition of inquiries rather than responding to them, using you to represent I, and fascination with things that are lyrical in nature such as a song or verse are typical speech pattern abnormalities for children diagnosed with ASD. Stuttering is not a clinical manifestation associated with ASD.
A nursing student notices a father yelling at his toddler for not coloring within the lines. According to Erikson's model, what outcomes is this child at risk for? (Select all that apply) A. Self-doubt B. Helplessness C. Autonomy D. Self-Control E. Dependence on caregivers
A. Self-doubt B. Helplessness E. Dependence on caregivers This toddler is in the autonomy vs shame and doubt level. By negatively reacting to the child's failure, the father is putting the toddler at risk of self-doubt, helplessness, and dependence rather than autonomy and self-control
A nurse is assessing a child for manifestations of Down Syndrome. What characteristics should she assess for? (Select all that apply) A. Small ears that fold over slightly at the top. B. 2 palm creases C. Long neck D. Eyes slant upwards E. Large hands with long fingers
A. Small ears that fold over slightly at the top. B. 2 palm creases D. Eyes slant upwards Down syndrome is manifested by small ears that fold over slightly at the top, 2 palm creases (known as a simian crease), and a slight upward slant of the eyes. Other characteristics include a flat face, short, bridged nose, and small arched palate. It is characterized by a short, broad neck, and short, stubby fingers, not a long neck or large hands.
A charge nurse is instructing a new nurse about side effects of ibuprofen and acetaminophen. What is a major side effect of both medications? A. Stevens-Johnson Syndrome B. Pain relief C. GI bleeding D. Fever reduction
A. Stevens-Johnson Syndrome A major side effect of both medications is Stevens-Johnson syndrome. Pain relief and fever reduction are intended effects of the medications, while GI bleeding is a side effect of Aspirin.
The nurse suspects an infant has failure to thrive (FTT). For which reason should the nurse anticipate this client being hospitalized? (Select all that apply.) A. Teach the caregivers how to identify physiologic hunger cues B. Provide adequate caloric and nutritional intake C. Protect the child from the caregivers D. Promote growth and development E. Assist in establishing a feeding routine
A. Teach the caregivers how to identify physiologic hunger cues B. Provide adequate caloric and nutritional intake D. Promote growth and development E. Assist in establishing a feeding routine Rationale: A client with FTT does not necessarily need protection from the caregivers. The goal of treatment for a client with FTT is to promote growth and development, establish feeding and sleep patterns, provide adequate caloric and nutritional intake, and teach the caregivers how to recognize hunger cues.
During a routine examination, the mother mentions that her 13-year-old son is constantly eating and is rapidly growing out of most of his clothes. Which statement should the nurse include in the response to the mother? (Select all that apply.) A. "You can expect height and weight increases to last over the next few years." B. "Nutritional needs increase with growth spurts." C. "Most growth at this age takes place in long bones of the arms and legs." D. "Boys often experience a prepubescent growth spurt at this age." E. "Growth in all children occurs in a cephalocaudal direction."
A. "You can expect height and weight increases to last over the next few years." B. "Nutritional needs increase with growth spurts." D. "Boys often experience a prepubescent growth spurt at this age." Rationale: The prepubescent period is marked by a growth spurt at about age 10 for girls and 13 for boys. Nutritional needs increase with growth spurts, and there is dramatic height and weight increase (usually over a period of 2-3 years). Growth in infants occurs in a cephalocaudal direction, but not in this stage. Although bone growth is continuing, the majority of long bone growth does not occur in this stage.
The nurse is teaching a group about the cognitive theory of development. The nurse determines that teaching has been effective when the group identifies which components of the cognitive theory of development? A. Assimilation, accommodation, and adaptation B. Self-efficacy, temperament, and adaptation C. Assimilation, adaptation, and self-efficacy D. Assimilation, resilience, and temperament
A. Assimilation, accommodation, and adaptation Rationale: The cognitive theory of development includes assimilation, accommodation, and adaptation. Self-efficacy is a component of social learning theory. Temperament is a component of the temperament theory of development. Resilience is a component of the resilience theory.
A charge nurse is teaching a new nurse about Down Syndrome. Which response by the nurse proves that education was successful? A. "Down syndrome is a disorder of emotional impairment." B. "Down syndrome is a disorder of intellectual impairment." C. "Down syndrome is also known as Bisomy 34." D. "There are no medical risks associated with children with down syndrome."
B. "Down syndrome is a disorder of intellectual impairment Down syndrome is a disorder of intellectual impairment, not emotional impairment. It is also known as Trisomy 21, not Bisomy 34. Many children born with down syndrome have increased risk of developing heart defects, renal issues, altered immune functions, skeletal defects, and infertility in males/ lower fertility in females
Dr. IK Now gives you a telephone order iburprofen 220 mg tablets PO PRN for your 13 year old patient admitted for a GI bleed. What is the nurse's best response to the doctor? A. "Are there any other orders you would like me to put in for you?" B. "I'm sorry doctor, but are you sure you want to order mortin for this patient?" C. "Can we order tylenol as well?" D. "What are your plans for dinner tonight?"
B. "I'm sorry doctor, but are you sure you want to order mortin for this patient?" The nurse recognizes that ibuprofen is contraindicated in patients with gastric bleeding or peptic ulcers as it may intensify the effects of bleeding in the patient.
The nurse is assessing a 3-year-old child with autism spectrum disorder (ASD). In which area should the nurse expect to find impairments? (Select all that apply.) A. Ability to engage in complex thought process B. Communication C. Social adaptability D. Social interactions E. Ability to organize responses to situations
B. Communication C. Social adaptability D. Social interactions E. Ability to organize responses to situations Rationale: Impairments are noted in the social interactions and ability to adapt socially at the appropriate age level. The young child with ASD will have a decreased ability to communicate as well as an inability to organize situational responses. Developmentally, the 3-year-old is not old enough for complex thought.
The nurse is teaching about Piaget's theory of cognitive development. The nurse assesses that teaching has been effective when the nurses correctly identify which phase associated with Piaget's theory? (Select all that apply.) A. Accommodation phase B. Concrete operational phase C. Assimilation phase D. Preoperational phase E. Sensorimotor phase
B. Concrete operational phase D. Preoperational phase E. Sensorimotor phase Rationale: Piaget's theory consists of the following phases: sensorimotor, preoperational, concrete operational, and formal operational phases. Assimilation and accommodation are abilities that an individual uses to progress through the phases of cognitive development.
The parents of a child with cerebral palsy (CP) are concerned about possible future health problems. The nurse knows the client is at risk for which complication? (Select all that apply.) A. Hypotension B. Depression C. Urinary incontinence D. Decreased cognitive ability E. Premature aging
B. Depression C. Urinary incontinence D. Decreased cognitive ability E. Premature aging Rationale: The client with CP is at risk for multiple comorbidities to include depression, decreased cognitive ability, urinary and bowel incontinence, and premature aging. The client with CP is at risk for developing hypertension, not hypotension.
Which intervention is most appropriate for the nurse to include in the plan of care for a child with autism spectrum disorder (ASD)? A. Putting the television on loud to provide stimulation for the client B. Encouraging the client's family to bring in familiar objects from home C. Rearranging the hospital room until a comfortable arrangement is found D. Scheduling procedures for different times each day
B. Encouraging the client's family to bring in familiar objects from home Rationale: Clients with ASD need structure and a predictable course of action. Bringing in familiar objects from home provides comfort for the client. It is important for the nurse to be oriented to the room and care should be taken not to relocate objects in the environment. Clients with ASD are sensitive to loud noises and bright lights, so the television should be turned off to minimize stimuli that may distress the client. Procedures should be scheduled for the same time to maintain predictability.
The nurse is teaching the parents of a client with growth and development alterations. Which independent intervention should the nurse provide to the client or family? (Select all that apply.) A. Prescribe medication for treatment B. Facilitate connections with support groups and financial aid services C. Provide speech therapy D. Provide instruction on the creation of a safe home environment E. Ensure the client is properly fitted with orthotic devices, if prescribed
B. Facilitate connections with support groups and financial aid services D. Provide instruction on the creation of a safe home environment E. Ensure the client is properly fitted with orthotic devices, if prescribed Rationale: The nurse should facilitate connections with support groups and financial aid services, provide instruction on the creation of a safe home environment, and ensure that the client is properly fitted with orthotic devices. The nurse cannot prescribe medication or provide speech therapy.
The nurse is assessing a 4-month-old infant. Which developmental milestone should the nurse expect the infant to have mastered by this time? (Select all that apply.) A. Sits without assistance B. Forms hand into a fist C. Looks at and plays with own fingers D. Holds a bottle E. Turns head toward voices and sounds
B. Forms hand into a fist C. Looks at and plays with own fingers E. Turns head toward voices and sounds Rationale: An infant that is 4 months old should have met the following milestones: forming hands into a fist, looking at and playing with own fingers, and turning head toward voices and sounds. Sitting without assistance happens around 8 months. Holding a bottle occurs between 4 and 6 months.
The nurse is assessing a toddler client for an upper respiratory infection. The nurse suspects the child may have autism spectrum disorder (ASD). Which behavior caused the nurse's suspicion? A. Speaking to the nurse in sentences B. Having a tantrum when touched by the nurse C. Playing with the other children and toys while awaiting the nurse D. Crying after the administration of immunizations
B. Having a tantrum when touched by the nurse Rationale: An assessment finding that supports the diagnosis of ASD is having a tantrum when touched by the healthcare provider. It is not uncommon for the child with ASD to display an inability to attend and systematize situational reactions. Playing with other children, speaking to the nurse in sentences, and crying after the administration of immunizations are not findings that support ASD. These assessment findings are age appropriate for the client.
The nurse is teaching a new mother about infant care. Which should the nurse include to prevent the development of failure to thrive (FTT)? (Select all that apply.) A. Use of formula supplements B. Importance of touch C. Establishment of trust D. Auditory stimulation E. Expected development changes
B. Importance of touch C. Establishment of trust D. Auditory stimulation Rationale: Infants who are deprived of mothering, especially those who are 3 to 15 months of age, will not learn to form significant relationships or to trust others. Touch, cuddling, and visual and auditory stimulation are all critical for the infant. Through these mechanisms, the baby comes to know self and the environment. Infants who fail to establish a loving, responsive relationship with a caregiver often fail to develop normally. Formula supplements and expected developmental changes will not necessarily prevent the development of FTT.
An 18-month-old client is suspected of having cerebral palsy (CP). Which test should the nurse expect to be prescribed to help diagnose this client? (Select all that apply.) A. Electrocardiographic studies B. MRI C. CT scan D. PET scan E. Laboratory studies of protein levels in the bloodstream
B. MRI C. CT scan D. PET scan Rationale: There is no specific diagnostic test for CP, but MRI, CT scan, and PET scan can be helpful in eliminating other organic brain disease, such as tumors or developmental issues. Electrocardiographic studies and laboratory studies are not used to diagnose CP.
The nurse is teaching the parents of a child with autism spectrum disorder (ASD) who is being treated with a gluten-free and casein-free diet. Which food should the nurse teach the parents to eliminate in the child's diet? (Select all that apply.) A. Beef B. Milk C. Corn D. Grain E. Cheese
B. Milk D. Grain E. Cheese Rationale: Foods that should be avoided include grains and dairy products, such as milk and cheese. Corn and beef can be consumed when following a gluten-free and casein-free diet. Clients considering a gluten-free and casein-free diet should be referred for counseling, so as to be able to meet the child's nutritional needs.
The nurse is discussing developmental theories with a parent group. Which theory should the nurse identify as involving the development of right and wrong? A. Resilience theory B. Moral theory C. Ecologic theory D. Spiritual theory
B. Moral theory Rationale: The moral theory of development is a complex theory that involves the development of values necessary to live with others in society. Ecologic theory involves the development of hereditary capability versus environmental effects. Resilience theory refers to the ability to function with healthy responses in situations of high stress and adversity. Spiritual theory deals with the development of an understanding of how an individual finds meaning in relation to her world.
The parents of a child with cerebral palsy (CP) ask if there are any medications available to help control the child's symptoms. Which type of medication should the nurse discuss with the parents? (Select all that apply.) A. Antidepressants B. Muscle relaxants C. Botulinum toxin D. Baclofen E. Benzodiazepines
B. Muscle relaxants C. Botulinum toxin D. Baclofen E. Benzodiazepines Rationale: Medications that are used to control seizures and spasms include skeletal muscle relaxants, baclofen, benzodiazepines, and botulinum toxin. Antidepressants are not used to manage the symptoms of CP.
The nurse is caring for a family with a toddler experiencing gross motor delays. From which member of the interprofessional team should the nurse request an order for a consult for an evaluation? A. Child psychologist B. Physical therapist C. Occupational therapist D. Speech therapist
B. Physical therapist Rationale: Gross motor delays need to be evaluated by a physical therapist. Language delays would be evaluated by a speech therapist. An occupational therapist can help with fine motor delays. A child psychologist would be consulted for overall cognitive delays.
The nurse is caring for a 9-year-old client who was injured while riding a bicycle down a steep hill while the client's mother was at work. Which underlying safety issue should the nurse address? (Select all that apply.) A. Determine the nutritional status of the child. B. Review the importance of wearing protective gear, such as helmets and long-sleeved clothing, while riding bicycles. C. Review the physical and emotional needs of latchkey children with the mother. D. Investigate possible emotional triggers for risky behavior, such as choosing to bike down a steep hill. E. Address whether a peer group is encouraging risky behavior.
B. Review the importance of wearing protective gear, such as helmets and long-sleeved clothing, while riding bicycles. C. Review the physical and emotional needs of latchkey children with the mother. D. Investigate possible emotional triggers for risky behavior, such as choosing to bike down a steep hill. E. Address whether a peer group is encouraging risky behavior. Rationale: The nurse should review bicycle safety, peer involvement, latchkey children's emotional needs, and reasons for risky behavior. Bicycle safety is important given the history of a serious accident. School-age children are often "latchkey" children, old enough to stay alone while a mother is at work, but they have physical and emotional needs that need to be addressed carefully. Otherwise, they may find a negative peer group or engage in risky behaviors to act out. The nutritional status of the child is not relevant to risk for injury.
The nurse is preparing discharge instructions for the parents of a child with cerebral palsy (CP). Which instruction should the nurse include to promote safety for this child? (Select all that apply.) A. Range-of-motion exercises B. Seat belts in strollers and wheelchairs C. Splints and braces D. Helmet to protect against head injuries E. Adaptive seating for automobile transportation
B. Seat belts in strollers and wheelchairs D. Helmet to protect against head injuries E. Adaptive seating for automobile transportation Rationale: A client who has frequent falls and/or seizures may require a helmet to protect against head injury. Adaptive seating in an automobile may be required to ensure proper, safe restraint. Use of seat belts in wheelchairs or strollers will prevent spastic movements from resulting in falls. Use of splints and braces and range-of-motion exercises will promote mobility and muscle strength; they are not used to promote safety.
The nursing student notes that a child shows signs of sucking, rooting, and grasping. Based on what she learned in nursing school, the nurse knows this child is in what phase of Piaget's model? A. Preoperational Phase B. Sensorimotor Phase C. Concrete operational phase D. Formal Operational Phase
B. Sensorimotor Phase Sucking, rooting, and grasping are all aspects developed in the sensorimotor phase of Piaget's model. This phase usually lasts from birth to 2 years.
Which measure should the nurse suggest for toddler-proofing a home? (Select all that apply.) A. Placing toddlers on their backs in bed, without blankets and in warm clothing B. Storing and locking up cleaning supplies and medications out of reach C. Choosing age-appropriate toys that do not pose a swallowing hazard or injury risk D. Cutting foods properly to prevent choking hazards E. Providing gym equipment on a hard surface
B. Storing and locking up cleaning supplies and medications out of reach C. Choosing age-appropriate toys that do not pose a swallowing hazard or injury risk D. Cutting foods properly to prevent choking hazards Rationale: Choking, injuries, and poisoning are primary concerns for toddler safety. Toys should be age-appropriate so that toddlers cannot swallow them and block an airway or injure themselves on sharp corners. Food should be cut properly to prevent choking. Cleaning supplies and medications need to be locked away and out of reach to prevent poisoning. Positioning toddlers in bed without blankets and on their backs is inappropriate; this intervention prevents sudden infant death syndrome (SIDS) in babies, but children need warmth from blankets and can sleep in any position. Gym equipment should be placed on a soft surface so that children will not be injured from falls.
The nurse is teaching an older adult client with geriatric failure to thrive (GFTT) about nutritional supplementation. Which supplemental vitamin should the nurse include in this teaching? A. Vitamin C B. Vitamin D C. Vitamin A D. Vitamin E
B. Vitamin D Rationale: Pharmacologic therapies for the treatment of GFTT typically involve vitamin regimens. Vitamin D is one of the most commonly prescribed supplements for GFTT clients. Vitamins A, C, and E are not nutritional supplements for GFTT.
The nurse evaluates teaching provided to a group of new parents on failure to thrive (FTT). Which statement should indicate to the nurse that teaching was effective? (Select all that apply.) A. "Breastfed babies never develop FTT." B. "FTT can often be prevented by classes such as this one." C. "Misinterpreting hunger cues can lead to FTT." D. "Many people think all Asian children have FTT; the truth is they are just small and never get the disorder." E. "The majority of FTT cases are not related to a physical problem."
B. "FTT can often be prevented by classes such as this one." C. "Misinterpreting hunger cues can lead to FTT." E. "The majority of FTT cases are not related to a physical problem." Rationale: FTT is often caused by misinterpreting hunger cues. The majority of FTT cases are not related to physical problems. FTT can often be prevented by educating the parents and caregiver. FTT can develop in any client. Breastfed babies can develop FTT.
The nurse taught a group of high school students actions to prevent injury. Which student comment indicates an understanding of the teaching? (Select all that apply.) A. "I do not need to wear a seat belt as a passenger in a car." B. "If I feel really down, I need to talk to my parents about it." C. "I should not get into a car when the driver has been drinking." D. "I hate it, but I will wear a helmet when riding my bike." E. "I can talk to a teacher if I am faced with peer pressure to use drugs."
B. "If I feel really down, I need to talk to my parents about it." C. "I should not get into a car when the driver has been drinking." D. "I hate it, but I will wear a helmet when riding my bike." E. "I can talk to a teacher if I am faced with peer pressure to use drugs." Rationale: Nursing actions to reduce the risk for unintentional injury in the adolescent include teaching on the use of seat belts and helmets, discussing drug and alcohol use and risk for suicide, and discussing the risk for traumatic brain injury. The student who states there is no need to wear a seat belt as a passenger in a car would require further teaching. The statements of the other students indicate that teaching has been effective.
The nurse is teaching a caregiver about treatment for failure to thrive (FTT). Which statement made by the caregiver should indicate the need for further teaching? (Select all that apply.) A. "Nutritional supplements will help meet the caloric requirements." B. "Medications are given daily to treat this condition." C. "I hope my baby will not need surgery; that idea scares me." D. "Most babies do not sleep well anyway; my baby will sleep when she is tired." E. "I can monitor height and weight at home to see if any progress is being made between doctor visits."
B. "Medications are given daily to treat this condition." C. "I hope my baby will not need surgery; that idea scares me." D. "Most babies do not sleep well anyway; my baby will sleep when she is tired." Rationale: Treatment of FTT includes reestablishing eating and sleeping patterns for the client. Surgery is necessary only if an organic cause of FTT is identified. There are no medications used in the treatment of FTT. Monitoring height and weight to assess progress and providing nutritional supplements indicate appropriate understanding of treating FTT.
A mother hits her call light and tells the nurse her toddler, who was admitted for the flu, is complaining of a headache. She wants you to give the child some aspirin. What is the nurses best response? A. "Let me call the provider and get that right away." B. "Get it yourself. It's an otc drug anyway." C. "I'm sorry, but it is bad to give your toddler Aspirin as it may cause a rare condition called Reye's Syndrome." D. "You'll have to wait until breakfast comes, as aspirin should be taken on a full stomach."
C. "I'm sorry, but it is bad to give your toddler Aspirin as it may cause a rare condition called Reye's Syndrome." Any child that has recently had a viral infection such as the flu or varicella (chickenpox) is at risk for developing Reye's syndrome if given aspirin.
The nurse is teaching a group of parents about normal development of an infant 6-8 months old. Which response by the parents indicate further teaching is needed? A. "My baby should be able to transfer objects from one hand to the other." B. "My child recognizes their own name by this time and responds by smiling." C. "My baby will not be able to sit alone, unsupported for another 2 months." D. "By now, most of my child's inborn reflexes are gone."
C. "My baby will not be able to sit alone, unsupported for another 2 months." By 8 months, a child should be able to sit alone steadily without support. Indication that the child will not be able to do so until 10 months should be addressed by the nurse.
The nurse notices the infant of a client is grasping for her necklace during a routine assessment. Based on this action, the nurse knows the child is probably how old? A. 4-6 months B. 7 months C. 2-3 months D. 10 months
C. 2-3 months By 2-3 months, a child should be grasping for objects.
hich resource should the nurse expect the healthcare provider to use to confirm the diagnosis of autism spectrum disorder (ASD)? A. Teaching Social Communication to Families with Autism B. The Mental Health Rights Manual C. Diagnostic and Statistical Manual of Mental Disorders D. The Autism Handbook
C. Diagnostic and Statistical Manual of Mental Disorders Rationale: Criteria for diagnosis can be found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), which includes screening tests to identify tendencies consistent with ASD. Although the other resources may be helpful in teaching the client and the family about ASD, they are not used as a diagnostic tool.
The mother of a 4-year-old child with cerebral palsy (CP) asks how this health problem occurred. Which prenatal insult should the nurse explain as a possible cause? (Select all that apply.) A. Brain injury B. Hyperbilirubinemia C. Fetal viral infection D. Genetic factors E. Prematurity
C. Fetal viral infection D. Genetic factors E. Prematurity Rationale: Prematurity is an etiology of CP that occurs before birth. Fetal viral infection is an etiology of CP that occurs before birth. Genetic factors are an etiology of CP that occurs before birth. Hyperbilirubinemia is an etiology of CP that occurs after birth. Brain injury is an etiology of CP that occurs after birth.
A 1-year-old child is being evaluated for cerebral palsy (CP). Which finding should the nurse least expect to assess in this client? A. Arching of the back B. Strabismus C. Normal muscle tone in all extremities D. Developmental delay
C. Normal muscle tone in all extremities Rationale: Infants and children with CP do not exhibit normal muscle tone. Infants with cerebral palsy often exhibit arching of the back. Children with CP often experience delay in reaching developmental milestones. Strabismus is seen in children with CP.
The nurse is planning care for a client with failure to thrive (FTT). Which goal should the nurse identify for this client? A. Parental understanding of the child's trauma prevention B. Parental understanding of the child's safety C. Parental understanding of the child's nutritional requirements D. Parental understanding of the child's stress and coping
C. Parental understanding of the child's nutritional requirements Rationale: Attaining adequate growth and normal development of the child, improving the parent-child relationship and the parental understanding of the child's nutritional requirements, and preventing complications associated with poor nutrition should be the goals of nursing care for the child with FTT. Safety, stress and coping, and prevention of trauma are not appropriate goals for the client with FTT.
A 7-year-old client with cerebral palsy (CP) is learning to self-feed. Which action should the nurse encourage to promote independence and success with self-feeding? A. Reassuring the child that having to be fed is nothing to be ashamed of B. Restricting attempts at self-feeding to 5 minutes C. Providing large, padded eating utensils D. Assisting the parents with total feeding
C. Providing large, padded eating utensils Rationale: Providing large, padded utensils makes self-feeding easier and facilitates success with this endeavor. Children with CP should be encouraged to do as much as they can for themselves. Insisting on total feeding or not allowing prolonged periods of time to practice self-feeding does not help encourage independence.
The nurse is writing a plan of care for a client with failure to thrive (FTT). Which goal should the nurse make a priority for this client? A. Complications from poor nutrition will be prevented. B. The parent-child relationship will improve. C. The child will attain adequate growth and normal development. D. The child will sleep through the night.
C. The child will attain adequate growth and normal development Rationale: All the listed goals are important, but FTT is a feeding disorder and represents malnutrition. It is a priority for the client to have improved nutrition to assist with growth and development.
A CP patient is admitted to your floor for a procedure. In the morning, the doctor will implant a Baclofen pump. The nurse knows the reason for this pump is: A. So the client does not have to remember to take their medication B. To control the patient's recurring headaches C. To allow direct administration of the drug to decrease spasmotic behavior. D. Because the doctor said so
C. To allow direct administration of the drug to decrease spasmotic behavior. A Baclofen pump is implanted to allow direct administration of the drug to control muscle spasms. It is indicated when oral administration is ineffective or causes adverse side effects
Which instruction should the nurse include when teaching parents strategies to enhance communication with a child diagnosed with autism spectrum disorder (ASD)? (Select all that apply.) A. Using complex words to stimulate the child's vocabulary B. Speaking loudly C. Using pictures, computers, or other visual aids D. Considering using sign language E. Using short, direct sentences
C. Using pictures, computers, or other visual aids D. Considering using sign language E. Using short, direct sentences Rationale: Clients with ASD have impaired communication skills. Strategies to improve communication include using short, direct sentences that are easy to understand, supplementing verbal communication with the use of pictures, computers, or other visual aids, and using sign language. Deafness is not a clinical manifestation of ASD, so speaking loudly will not improve communication and will distress the client. Simple, not complex, words and sentences are best for communication with the client with ASD.
A client is diagnosed with geriatric failure to thrive (GFTT). Which finding should the nurse use to justify this diagnosis? A. Increased homeostasis B. Weight loss of more than 15% of baseline body weight C. Weight loss of more than 5% of baseline body weight D. Increased social interaction
C. Weight loss of more than 5% of baseline body weight Rationale: Geriatric failure to thrive (GFTT) is a condition in which older clients experience a weight loss of more than 5% of baseline body weight, decreased appetite, undernutrition and dehydration, depression, and cognitive and immune impairment. GFTT does not increase homeostasis. This health problem could lead to or be caused by social isolation. A weight loss of more than 15% of baseline body weight is severe malnutrition requiring medical intervention.
The caregiver of a 30-year-old client with cerebral palsy (CP) asks if there are any changes in health that might develop. Which response should the nurse make? A. "People with CP don't often live past 30." B. "It is impossible to predict which health changes he will experience." C. "He will likely develop signs of premature aging as a result of constant stress on the body." D. "He will gradually become more and more independent as the spasticity in the muscles diminishes."
C. "He will likely develop signs of premature aging as a result of constant stress on the body." Rationale: In clients with CP, constant stress on the body can cause premature aging. Conditions such as hypertension, osteoarthritis, and atherosclerosis often develop before age 40. Numerous clients with CP do live past age 30, and this is increasing as symptom management becomes more effective. Independence usually does not increase as a result of aging, but the manifestations may become more severe or result in further complications.
The nurse is assessing a child at the 1-year well-child visit. The child is alert and calm but does not follow or reach for the toy the nurse is moving back and forth. This is a significant change from the child's 6-month visit. Which response by the nurse, to the parents, is most appropriate? A. "Has the child hit her head or had any injuries since the last well-child visit?" B. "This is concerning. You may want to think about physical therapy for your child." C. "Let's have the healthcare provider complete an evaluation, then we can talk." D. "I wouldn't worry; it is close to the child's naptime and she is probably just tired."
C. "Let's have the healthcare provider complete an evaluation, then we can talk." Rationale: When there is a significant change from one well visit to the next, the nurse must be aware this requires an evaluation. Once the healthcare provider completes an assessment, the nurse can discuss any concerns with the parents and what steps should be taken. It is not appropriate to dismiss the change and attribute it to the child being tired. Asking if there has been a head injury is likely to frighten the parents unnecessarily. It is outside of the nurse's scope of practice to refer to physical therapy.
Which teaching point is important for the nurse to include in the plan of care for a client who is diagnosed with autism spectrum disorder (ASD)? A. Keeping the same pediatric healthcare provider for all children in the family B. Maintaining the home as a treatment-free zone C. Focusing on limitations in order to see progress in care D. Establishing a routine
D. Establishing a routine Rationale: Clients who are diagnosed with ASD thrive when routines are established and followed. The family should consider seeking a healthcare provider who has experience in treating a child with ASD. Therapies must be practiced and implemented in the home environment in order to be effective. The family would focus on the child's strengths, not the child's limitations.
An 8-month-old baby with failure to thrive (FTT) is being discharged. Which goal should the nurse identify for this client? A. Increase activity. B. Increase interaction with others. C. Adhere to a feeding schedule. D. Improve nutritional intake.
D. Improve nutritional intake Rationale: Nursing care of the child with FTT is directed toward improving the child's nutritional intake with the goal of increasing the growth and health of the child. This may be accomplished through parent teaching; observation of child-parent interactions, especially during feeding times; and careful recording of height and weight on growth charts. Increased activity would burn more calories. A schedule in and of itself would not address the improved intake. Increased interaction would only be a benefit if it improved nutrition.
The nurse is observing a classroom of children for normal growth and development. Which sighting by the nurse should indicate a child is not progressing at a normal pace? A. A 10-12 month old holds crayons and scribbles on a piece of paper B. A 1&1/2 year old throws a ball C. A 3 year old kicks a ball D. A 2 year old builds a tower of 2 blocks
D. A 2 year old builds a tower of 2 blocks By the age of two, the child should be able to build a tower of at least 4 blocks. A tower of two blocks may indicate a delay in fine motor development. All other answers are normal developments for their age groups.
The nurse finds a 14-year-old client watching MTV at full blast. Which safety issue should the nurse address with the client? A. It is not wise for the client to argue with parents about watching MTV. B. It is inappropriate for the client to watch MTV. C. The noise is making it hard for the nurse to chart. D. Adolescents need to be reminded that loud music can lead to hearing loss.
D. Adolescents need to be reminded that loud music can lead to hearing loss. Rationale: Although the noise may be disturbing the nurse's work and the client's parents may not want the client to watch MTV at high volume, these are not the safety concerns the nurse needs to address. Listening to music and television at a high-decibel volume can lead to hearing loss.
The student nurse enters a simulation with a pregnant mannequin. The fetal O2 sat is dropping. The student nurse knows that fetal hypoxia is commonly believed to put the patient at risk for which disease? A. Down syndrome B. Autism C. NOFTT (Non-organic Failure to Thrive) D. Cerebral Palsy
D. Cerebral Palsy Fetal hypoxia is believed to be a major cause of cerebral palsy. Other causes are believed to be maternal infections, teratogens (Alcohol abuse), preterm birth, and being dropped/shaken as a baby
The nurse is teaching new mothers about safe sleeping for newborns. Which recommendation should the nurse include? A. Keep newborns on their stomachs while in the crib and cover them with a warm blanket. B. Place newborns on their sides and cover with a light blanket. C. Cover newborns up to the shoulder with a warm blanket and put them on their backs. D. Dress newborns in warm clothing and place them on their backs while in a crib.
D. Dress newborns in warm clothing and place them on their backs while in a crib. Rationale: Research has shown that the best way to prevent sudden infant death syndrome (SIDS) is to place infants in a crib or bassinette on their backs. Dress the infant in warm clothing and do not use blankets because they could move out of position and smother the infant. Infants should not be placed on their stomachs or sides.
The nurse is caring for a client with Down syndrome who likes to say "hi" to everyone and strike up conversations. Which important safety information should the nurse teach the caregivers? A. Keep the client in a restrictive environment. B. Tell the client not to bother strangers. C. Make sure to tell the client to shake hands with strangers. D. Monitor the client's interactions to make sure the client is engaging with safe people.
D. Monitor the client's interactions to make sure the client is engaging with safe people. Rationale: The client's caregivers will need to monitor the client's interactions with strangers because the client may have no awareness that some people can be dangerous. The client has a right to be in the least restrictive environment, and if the client's social interactions can be safely supervised, socialization is beneficial for the client. Teaching the client to shake hands is not a safety consideration. Telling the client not to bother strangers is not therapeutic and could cause harm to the client's feelings.
The nurse assesses that a client has reached physical growth milestones but has not achieved cognitive developmental milestones. Which factor should the nurse consider other than developmental disorders? A. Cerebral palsy B. Child temperament C. Genetic abnormalities D. Parental interaction
D. Parental interaction Rationale: Family is an important environmental factor that plays an essential role in child development. Parenting influences risk and protective factors, personality characteristics, and developmental outcomes. Cerebral palsy is a physical disability. Genetic abnormalities would typically impact both growth and development. Child temperament is not a known factor that would impact the ability to achieve cognitive developmental milestones.
Which activity should be appropriate for the nurse to suggest to parents to aid in the development of their toddler's gross motor skills? A. Coloring with large crayons B. Doing wooden puzzles C. Using a toy telephone D. Playing with a soft ball and bat
D. Playing with a soft ball and bat Rationale: The toddler from age 1-3 years old can develop gross motor skills by such activities as playing with a soft ball and bat, riding a big wheel tricycle, molding water and sand, and tossing a ball or beanbag. Fine motor skills would be refined with the other choices.
The doctor orders Acetaminophen 325 tablets PRN for your 16 year-old patient, but forgets to put a reason for the order. The nurse knows that she must call the doctor and clarify the order pertaining to what vital sign: A. BP 110/62 B. Pulse 92 C. SPO2 of 95% D. Temp of 101.3
D. Temp of 101.3 The nurse knows that a temperature of 101.3 is an indication for tylenol because of its use as an antipyretic. All other vitals are WNL.
