Developmental Stages

The nurse has reinforced information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further teaching?

"I should have my child sit on the potty until my child urinates."

The nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further teaching if the parent makes which statement?

"I should feed my child if she will not eat."

The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE?

"I don't need to do that; I'm too old for that."

When caring for a 3-year-old child, the nurse should provide which toy for the child?

A wagon

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to the figure.

3

During a routine well-child checkup for a 2½ year old, the nurse plans to teach the mother proper nutrition and weight gain expectations for her child. The nurse reviews the chart and finds that the toddler's birth weight was 7 pounds 15 ounces. The nurse expects that the child should weigh approximately how much at this time?

31 pounds 12 ounces

The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area? Refer to figure.

4

The nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child?

A 10-piece puzzle

The nurse is monitoring several older adults for adverse drug effects. Which client requires closest monitoring for drug toxicity?

A client who consumes a high-carbohydrate, low-protein diet

The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which?

A normal psychosocial response

A client who was struck by a car while jogging is brought to the emergency department by emergency medical services. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancé is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which should the nurse implement?

Close the deceased client's eyes and place gauze and a small ice pack on the eyes.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply.

Collect data to determine factors for fall risk. Instruct the client to ask for assistance when getting up to walk.

An older client is taking multiple medications for a variety of health problems. The nurse should monitor the results of which most important laboratory test(s) when evaluating adverse effects of medication therapy in the older adult?

Creatinine

The nurse is collecting data from an older adult client. Which indicates a potential complication associated with the skin of this client?

Crusting

When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply.

Decline in visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity?

Decreased lean body mass and glomerular filtration rate

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?

Determine the client's ability to follow verbal commands.

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take?

Document the findings.

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears. Extend touch, and hold the client or family member's hand if appropriate. Be honest and truthful, and let the client and family know that you will not abandon them.

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know that they will not be abandoned by the nurse.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should the nurse suggest to alleviate the child's fears?

Encourage the child's parents to stay with the child.

A client who has been seen in the clinic has been diagnosed with endometriosis and asks the nurse to describe this condition. Which is the best response for the nurse to provide?

Endometriosis is the presence of tissue outside the uterus that resembles the lining of the uterus.

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test?

Examines visual fields or peripheral vision

A nursing student enrolled in a physical assessment course is asked to describe the probable signs of pregnancy. The student displays correct understanding if the student lists which signs? Select all that apply.

Hegar's Chadwick's McDonald's

The nurse is collecting data from parents of a 2-year-old child about mealtime activities. The nurse expects a child this age to have attained which ability?

Holds a cup in one hand

The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition?

Hyperlipidemia

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?

Inspecting the abdomen

The nurse is preparing to perform an abdominal examination. Which step should be taken first?

Inspection

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent?

Irregular, noisy breathing and cold, clammy skin

The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority?

Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.

A client and her husband are being discharged from the hospital after delivering a stillborn infant. They ask about the possibility of attending a bereavement support group in the community. The nurse realizes this action corresponds to which aspect of grieving?

Normal grieving

A 1-month old child is hospitalized following a motor vehicle accident where the parents are seriously injured. The nurse should select which toys for this child? Select all that apply.

Nursery mobile A mobile that swings and plays music

The nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad because "his feet are always cold at night." The nurse should incorporate which concept when formulating a response to the family member?

Older adults often have slower neurological response times and are therefore more at risk for burns.

The nurse is reinforcing teaching about fall prevention to family members of an older client who is at risk for falls. The nurse realizes further instruction is necessary if the family states which concept is relevant to maintenance of balance for the older adult?

Older clients cannot think quickly enough to respond to emergencies.

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa

Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system?

Overall sclerotic lesions

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include? Select all that apply.

Perform TSE after a shower or bath. Perform TSE on the same day each month. Perform TSE by rolling each testicle between the thumb and fingers.

A pediatric nurse is caring for a hospitalized toddler. The nurse determines that which play activity would be appropriate for the toddler?

Playing with a push-pull toy

During data collection on a child for a well-child visit, a parent tells the nurse "We have a chore chart at our house. When our child does chores without prompting for 3 days in a row, the child gets an extra 30 minutes of screen time. So far, it seems to be working!" The nurse determines the child's behavior corresponds with which stage of Kohlberg's moral development?

Pre-conventional: Obtaining rewards

Which interventions are appropriate for the care of an infant? Select all that apply.

Provide swaddling. Hang mobiles with black-and-white contrast designs. Caress the infant while bathing or during diaper changes.

The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development?

Punishment-obedience stage

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test?

Remain with the family member without discussing funeral arrangements.

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take?

Report the observation to the primary health care provider.

In the well-child clinic, the nurse observes an infant, age 10 months, playing with toys, bringing them to his mouth, and passing the toys from one hand to the next. The nurse determines the child is in which Jean Piaget's first developmental stage?

Sensorimotor

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent?

Set limits on the child's behavior.

When reinforcing appropriate developmental skills interventions for a 1-year-old child who was born 2 months premature, the nurse should plan to encourage the parents to support the child to achieve which developmentally appropriate goal?

Sit independently.

The nurse instructs the unlicensed assistive personnel (UAP) assigned to care for an older adult client to place an extra blanket in the client's room. The nurse provides this instruction because the older adult is less able to regulate hot and cold body changes as a result of alterations in the activity of which gland?

Sweat glands

The nurse is preparing to assist the health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?

Testing the six cardinal positions of gaze

The nurse is caring for a hospitalized 5-year-old client. The nurse should recognize that which is normal for this child in this developmental stage?

The child believes the moon follows her.

The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child?

The child is exhibiting a normal pattern.

The nurse is collecting data regarding the motor development of a 24-month-old child. Based on the age of the child, the nurse expects to note which highest level of developmental milestone?

The child uses a doorknob to open a door.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

The nurse is employed in a newborn nursery. The nurse is reviewing all medications prescribed for newborns to prevent toxicity due to which causes? Select all that apply.

The liver is immature. The kidneys are less able to excrete medications

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?

The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands.

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse has gathered data regarding an older client. The nurse recognizes that which indicator of fluid imbalance is least likely to be reliable for a client in this age group?

Thirst

The nurse is working with a new nurse who is assisting an older client and family with discharge planning following hospitalization. The nurse realizes the new nurse correctly understands the needs of older adults if the new nurse helps the group plan for which situation?

To live independently, but close to their children if possible

Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly?

Asks the client to block one ear at a time

The nurse will be caring for several older adults who will be undergoing general anesthesia. Which older adult will require the closest monitoring for a prolonged effect of anesthesia?

An older adult with increased amount of fatty tissue

A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. The nurse identifies the child as displaying signs of which stage of Piaget's theory of cognitive development?

Animism

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development?

Good boy-nice girl orientation

A 4-year-old child is reluctant to take deep breaths following abdominal surgery. Which measure would be effective to encourage deep breathing?

Have the child pretend to be a big bad wolf blowing the little pig's house down.

The nurse should implement which activity to promote reminiscence among older clients?

Having storytelling hours

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?

"Adolescents love to sleep late in the morning."

A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse should make which suggestion to the mother?

"Allow the bottle if it contains water."

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?

"At this age, the child is developing his or her own personality."

The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response?

"This is common during hospitalization"

The nurse is assisting with data collection for a parent and son during a well-child visit. The nurse determines the child is in the phallic stage of Sigmund Freud's theory of personality development if the parent makes which comment?

"Yesterday my son asked me why he looked different from his sister."

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings should the nurse expect to observe because of meningeal irritation? Select all that apply.

The client reports stiffness and soreness in the neck area. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping? Select all that apply.

He expresses his anger at God and the primary health care providers for allowing this to happen. He tells the nurse he has prayed that God will allow his wife to live long enough to watch their children's high school graduation. He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites.

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.

Acute otitis media with effusion A physical obstruction to the transmission of sound waves

The nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse should distinguish which attribute of normal adolescents from an adolescent with depression?

Adolescents like to stay up late but rarely have insomnia.

The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse determines the UAP understands the information provided if the UAP identifies which situation portrays ageism?

Advising older adults to forgo aggressive treatment

A 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development?

Allow the child to participate in activities with other individuals in the same age group when the condition permits.

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents?

Allow the infant to signal a need.

The nurse should plan which to encourage autonomy in the client who is a resident in a long-term care facility?

Allowing the client to choose social activities

The nurse employed in a well-baby clinic is collecting data on the language and communication developmental milestones of a 4-month-old infant. Based on the age of the infant, the nurse expects to note which highest level of developmental milestones?

Babbling sounds

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?

Beginning of toilet training

The nurse is assessing the pain in a 3-year-old child after an appendectomy. Which pain scale should the nurse use?

FACES pain rating scale

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur?

Gentle, blowing or swooshing noise

The nurse determines a 5-year-old child is in the expected Erikson's psychosocial stage if the child makes which comment?

"I like drawing my mommy pictures with my finger paints."

The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. Which response by the nurse is appropriate?

"You may give the child a bottle if necessary, but if you do, it should contain water."

The nurse is collecting physical assessment data for a patient with possible splenomegaly. The nurse should palpate which abdominal quadrant? Refer to figure.

2

The nurse is reinforcing instructions to a 16-year-old male adolescent regarding dietary patterns. The nurse instructs the adolescent about the recommended amount of daily calories. How many calories a day does the nurse recommend as the approximate daily caloric allowance for a male adolescent?

2200

A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. After the session has been completed, the LPN recognizes the adolescents have understood the teaching if the adolescents identify the normal duration of the menstrual cycle is about how many days?

28 days

A 6-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child?

A board game

An older adult couple requests to room together at a long-term care facility. When some members of the staff question this, the nurse should provide which response?

Although responses may be slower, sexual ability is present in later years of life.

A client with sickle cell anemia has vaso-occlusive pain. After noting that the client is of preschool age, the nurse plans to use which method to determine the adequacy of pain control?

Ask the client to point to faces (smiling to very sad) that best describe the pain.

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which areas?

In the groove behind the medial malleolus and the Achilles tendon

The nurse is participating in a care plan session for a client with a terminal illness. Which nursing actions should be included? Select all that apply.

Respond to requests from the client and family promptly. Support the client's decision-making in order to promote client control. Provide information about what to expect during the dying process to the client and family.

The nurse is collecting data from a client who is suspected of having mittelschmerz. Which finding, on data collection, is most closely associated with this disorder?

Sharp pain located on the right side of the pelvis

The nurse in the pediatric unit is admitting a 2-year-old child. The nurse plans care, considering the child will likely display which behavior during Erikson's psychosocial stage of development corresponding with the age?

The child frequently says "no" when the parents or the nurse asks a question.

The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply.

Time and date of death Time of body transfer and destination Medical tubes, devices, or lines left in the body Name of primary health care provider certifying death

The nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which observation noted during the assessment would present the greatest hazard to the children?

Toys with small loose parts in the playroom

The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement?

Two thirds the distance between the antecubital fossa and the shoulder

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance?

Walking three to five times a week for 30 minutes

The nurse is caring for a 8-month-old infant. The nurse determines the child is at the expected developmental level if the child displays which behavior?

Waves bye-bye

The nurse is caring for a client at the end of life. Which skin changes would the nurse expect to note? Select all that apply.

Waxlike texture Mottling of arms, legs, hands, and feet Cyanosis of the nose, nail beds, and knees

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client?

Wheezes and use of accessory muscles

During a well-child checkup for a 4-month-old, the nurse reinforces instructing the mother how to introduce solid foods into her child's diet. Which statement indicates the mother needs further teaching?

"I will start giving home-prepared orange juice when my child is 3 months old."

The nurse determines an adolescent is showing progress toward completing Erikson's psychosocial developmental stages if the adolescent makes which statement?

"I've met people who like that kind of music and we're going to a concert next week."

The nurse is told by an older woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6.00 pm. Which is the nurse's best response?

"Incontinence at any age should be evaluated by your primary health care provider."

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory?

"Individuals move through all six stages in a sequential fashion."

The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse should make which suggestion to the mother?

"Inform the child of bedtime a few minutes before it is time for bed."

An older client confides to the visiting nurse the fear of falling while going to the bathroom at night. Considering the visual changes affecting the older client, the nurse should make which recommendation?

"Keep a red light on in the bathroom at night."

The nurse is reinforcing instructions to the mother of a 2-year-old child regarding dental care. Which statement by the mother indicates the need for further teaching?

"Proper dental care is not necessary for toddlers until their permanent teeth erupt."

A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old child?

"The child may ignore the parents when they visit."

The nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother what information? Select all that apply.

"The child should not be forced to sit on the potty for long periods." "The ability of the child to remove clothing is a sign of physical readiness." "Waiting until the child is 24 to 30 months old makes the task considerably easier." "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents."

The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which intervention?

Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization

The nurse is assessing a 36-month-old male 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, which should the nurse do next?

Assess the parents' body shape and stature.

The nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which finding would most likely assist in verifying the suspicion?

Bald spots on the scalp

The nurse is providing safety instructions to a group of parents who have children ages 8 and 9. Which car safety device should be used for a child who is 8 years old and is 4 feet tall?

Booster seat

The nurse is auscultating bowel sounds. Which are appropriate data collection methods and actions? Select all that apply.

Divide the abdomen into four quadrants at the umbilicus. Do not feed the client if no sounds are audible in 5 minutes. Listen in each quadrant for gurgling sounds indicating movement.

A client's spouse becomes distraught when thinking about his wife's terminal prognosis. Which action should the nurse implement to promote hope for the spouse?

Encourage formation of achievable goals.

The nurse is caring for a client at the end of life. Which gastrointestinal findings indicate that death is approaching? Select all that apply.

Nausea Incontinence Accumulation of gas Abdominal distention

The nurse prepares to discharge a fifty-year-old client who is experiencing family-related stress. Which goal does the nurse include to help the client achieve the primary developmental task?

Assist the client resume her familial role.

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered?

Autonomy vs. shame and doubt

During a well-child visit a mother states she is frustrated with her 2-year-old child. Whenever she asks him if he wants something to eat, he says, "No," but then he starts to cry when she does not give him the food. The nurse should provide which instruction to explain the psychosocial concepts related to growth and development of the toddler?

"Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt."

The nurse is caring for a 14-year-old boy who is hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?

Let the child wear his own clothing when friends visit.

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement?

"The moon follows me, and goes to bed when I go to bed".

The mother of a 4-year-old who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed and that it started when the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. Which nursing response is appropriate?

"This is a normal occurrence following hospitalization."

A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which should the nurse implement as the most effective measures to alleviate the spouse's distress? Select all that apply.

Engage the spouse in providing comfort. Encourage the spouse and client to hold hands.

The nurse is conducting a session on the process of fertilization with a group of nursing students. The nurse asks a nursing student to identify the structure in which fertilization of an ovum takes place. The nurse midwife recognizes the teaching has been effective if the student selects which location?

Fallopian tube

The nurse is caring for a client at the end of life. Which late cardiovascular and respiratory findings should the nurse expect to note while collecting data? Select all that apply.

Irregular heart rate Decreased pulse rate Decreased blood pressure Irregular breathing patterns

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply.

Listening to lung sounds Obtaining the client's temperature Obtaining information about the client's respirations

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 the child is thirsty. The family is attempting to give the child a large glass of apple juice. Which actions should the nurse take? Select all that apply.

Perform frequent oral care with mouth swabs. Encourage the family to participate in oral care as much as desired. Give the child small sips of water or ice chips if alert and requested by the child.

A licensed practical nurse (LPN) is providing instructions to an unlicensed assistive personnel (UAP) who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the UAP performs which action?

Places a dry sterile dressing over the open eyes

The nurse is caring for a client at the end of life. The client is withdrawn and agitated and is experiencing visual hallucinations. Which actions should the nurse take to provide end-of-life psychological care? Select all that apply.

Provide privacy to the client and family. Encourage the family to talk with and reassure the client. Encourage visits by appropriate spiritual services as desired.