Development/Human Development prep-U

The nurse is caring for a family of premature infant boy. The parents asks the nurse, "Why do we need to bring in the car seat we bought for him? He isn't going home for another week." What is the best response by the nurse? A. "The baby will be tested for oxygen desaturation while seated in the car seat" B. "We document the brand and size of the car seat." C. "The baby is not permitted to go home in an unapproved car seat." D. "We need to assure it is a safe car seat."

A. "The baby will be tested for oxygen desaturation while seated in the car seat" Explanation: The parents will be asked to bring in the car seat prior to discharge so the baby can be tested in the car seat to assure he doesn't have oxygen desaturation while seated in the car seat. While the seat must be safe and approved, the family will need to bring in the car seat well before discharge to assure the baby's respiratory status is stable in the car seat. Reference: Chapter 34: Caring for the Special Needs Child - Page 1199

The nurse is caring for a family of premature infant boy. The parents asks the nurse, "Why do we need to bring in the car seat we bought for him? He isn't going home for another week." What is the best response by the nurse? A. "The baby will be tested for oxygen desaturation while seated in the car seat" B. "We document the brand and size of the car seat." C. "We need to assure it is a safe car seat." D. "The baby is not permitted to go home in an unapproved car seat."

A. "The baby will be tested for oxygen desaturation while seated in the car seat" The parents will be asked to bring in the car seat prior to discharge so the baby can be tested in the car seat to assure he doesn't have oxygen desaturation while seated in the car seat. While the seat must be safe and approved, the family will need to bring in the car seat well before discharge to assure the baby's respiratory status is stable in the car seat. Reference: Chapter 34: Caring for the Special Needs Child - Page 1199

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse? A. "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." B. "The baby may have a problem; let's schedule an appointment." C. "This can be related to cleaning her perineal area; be more careful." D. "If this continues, call us back; for now, just watch her."

A. "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." Explanation: The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother's hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant's "bleeding" is not indicative of a pathologic process and should be careful to not upset the mother further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant's problem. The instruction to call back if it continues does not meet the mother's need to know why this is happening to her baby, and it negates her concern for her infant.

The mother of a 3-year-old tells the nurse that she is concerned that her child is not developing motor skills quickly enough. She states that, "My son can't skip and cannot stand on one foot for any length of time while playing." How should the nurse respond? A. "Your child is not expected to be able to perform those activities at 3 years of age." B. "I wouldn't be too concerned since he seems fine during my assessment." C. "Maybe practicing these activities with him would help him improve these motor skills." D. "I am sure he will become more proficient in these activities soon."

A. "Your child is not expected to be able to perform those activities at 3 years of age." Explanation: Skipping and standing on one foot for up to 10 seconds are motor skills that are expected from a 5-year-old, not a 3-year-old; therefore, the best response is letting the mother know that her child is not behind in motor development. Reference: Chapter 27: Growth and Development of the Preschooler - Page 987

The infant measures 21.5 in (54.6 cm) at birth. If the infant is following a normal pattern of growth, what would be an expected height for the infant at the age of 6 months? A. 27.5 in (70 cm) B. 30.5 in (77.5 cm) C. 29 in (74 cm) D. 32 in (81 cm)

A. 27.5 in (70 cm) Explanation: Infants gain about 0.5 to 1 in (1.25 to 2.5 cm) in length for each of the first 6 months of life. Therefore, a 21.5-in (54.6-cm) infant adding 6 in (15 cm) of growth would be 27.5 in (70 cm). Infants grow the fastest during the first 6 months of life and slow down the second 6 months. By 12 months of age, the infant's length has increased by 50%, making this infant 32 in (81 cm) at 1 year old. Reference: Chapter 25: Growth and Development of the Newborn and Infant - Page 924

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding? A. 30 to 60 breaths/min B. 60 to 80 breaths/min C. 12 to 20 breaths/min D. 80 to 100 breaths/min

A. 30 to 60 breaths/min Explanation: When assessing the respiratory rate of an infant less than 1 month of age, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or adults when they are at rest. Reference: Chapter 25: Vital Signs - Page 645

A nurse is caring for a pediatric client on an oncology unit. The family has asked that faith be included in developing the plan of care. Which belief's would be included according to Fowler's Theory of Faith Development? Select all that apply. A. Children imitate religious behaviors of others. B. The synthetic stage is seen as conventional faith demonstrated by young adults becoming responsible for their own beliefs. C. The school-age child is unable to understand the concept of reciprocal fairness. D. Courage, hope, and love compete with threats of abandonment. E. The relationship between self, values, and others is based on faith.

A. Children imitate religious behaviors of others. B. The synthetic stage is seen as conventional faith demonstrated by young adults becoming responsible for their own beliefs. D. Courage, hope, and love compete with threats of abandonment. Explanation: Based on Fowler's Theory of Faith Development children imitate religious behaviors of others, courage, hope, and love compete with threats of abandonment, and synthetic conventional faith is demonstrated by young adults becoming responsible for their own beliefs. However, the relationship between self, values, and others is based on trust. The school-age child is able to understand the concept of reciprocal fairness and can value the perspectives of others. Reference: Chapter 21: Developmental Concepts - Page 521-522

Enzymes that assist in the repair of deoxyribonucleic acid (DNA) defects by recognizing the defect, cleaving the abnormal chain, and then removing the distorted regions are known as: A. Endonucleases B. Ribonucleic acid C. Mutants D. Deoxyribonucleotides

A. Endonucleases Several repair mechanisms exist, and each depends on specific enzymes called endonucleases that recognize local distortions of the DNA helix, cleave the abnormal chain, and remove the distorted regions. The other options are not enzymes involved in this process. Reference: Porth, C. M. Essentials of Pathophysiology: Concepts of Altered Health States, 4th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Ch. 5: Genetic Control of Cell Function and Inheritance, p. 90. Chapter 4: Genetic Control of Cell Function and Inheritance - Page 90

An 80-year-old woman has had abdominal surgery following a bowel obstruction. The nurse is aware that the recuperation period for this patient will most likely be prolonged due to what common condition found in the elderly? A. Increased time for healing B. Presbyopia and presbycusis C. Slowed peristalsis D. Decreased core body temperature

A. Increased time for healing Explanation: While all of these conditions are age-related changes, the one that would affect the client's recovery time is increased time for recuperation and healing. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 423. Chapter 23: The Older Adult - Page 423

The nurse knows that during the transcription process, which of these is true of RNA? A. Polymerase attaches to DNA. B. Reverses redundant base pairs C. Exon sequences are reversed. D. Delivers activated amino acids

A. Polymerase attaches to DNA. During transcription, RNA polymerase recognizes the start sequence of a gene and attaches to the DNA. Exons are RNA sequences retained on the original RNA during splicing. tRNA delivers activated amino acids to proteins in the ribosome. When several triplet codons encode the same amino acid, the genetic code is said to be redundant. Reference: Chapter 4: Genetic Control of Cell Function and Inheritance - Page 61

Which gross motor skill would the 4-year-old child have most recently attained? A. The child can hop on one foot. B. The child can tie his/her shoelaces. C. The child can cut his/her food. D. The child can button his/her clothes.

A. The child can hop on one foot. Explanation: Gross and fine motor skills continue to develop rapidly in the preschool-aged child. Gross motor skills have to do with the development of large muscles. Balance improves around the age of 4, thus the child can hop on one foot and stand on one foot for 5 seconds. A 3-year-old child does not have the ability to accomplish these tasks. A 5-year-old child can button his/her own clothes, tie shoes, and cut his/her food. Reference: Chapter 27: Growth and Development of the Preschooler - Page 987

A nurse is teaching parents of preschoolers about growth and development of their children. Which teaching point would the nurse include? A. The pace of growth and development is specific for each person. B. Aspects of growth and development cannot be modified. C. Growth and development occur at similar stages and rates for each age group. D. Growth and development do not follow regular predictable trends.

A. The pace of growth and development is specific for each person. The pace of growth and development is specific and individualized for each person. Growth and development follow regular predictable trends, as noted by various developmental theorists. Growth and development do not occur at similar stages and rates for each age group. Aspects of growth and development can be modified. Reference: Chapter 21: Developmental Concepts - Page 511

The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele? A. The spinal meninges protrude through the bony defect and form a cystic sac. B. There is protrusion of the spinal cord and meninges, with nerve roots embedded. C. There is a bony defect that occurs without soft-tissue involvement. D. There is no protrusion of the spinal cord, only soft-tissue inflammation occurs.

A. The spinal meninges protrude through the bony defect and form a cystic sac. Explanation: When part of the spinal meninges protrudes through the bony defect and forms a cystic sac, the condition is termed spina bifida with meningocele. In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. A bony defect that occurs without soft-tissue involvement is called spina bifida occulta. Reference: Chapter 44: Nursing Care of the Child With an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder - Page 1607

A nursing student will pick which value as a correct laboratory value for a newborn? A. hemoglobin (Hbg) 17 g/dL (170 g/L) B. white blood cell (WBC) count 40,000/mm³ (40 ×109/L) C. hematocrit (Hct) 40% (0.4) D. platelet count 75,000/µL (75 ×109/L)

A. hemoglobin (Hbg) 17 g/dL (170 g/L) Explanation: The normal laboratory values for a newborn include Hgb 16 to 18 g/dL (160 to 180 g/L), Hct 46% to 68% (0.46 to 0.68), platelet count 4,500,000/µL to 7,000,000/µL, (4,500 to 7,000 ×109/L) and WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range. Reference: Chapter 17: Newborn Adaptation - Page 583

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds? A. in the woman's lower abdominal quadrant B. at the upper outer quadrant of the woman's abdomen C. at the level of the woman's umbilicus D. in the area above the woman's umbilicus

A. in the woman's lower abdominal quadrant Explanation: The fetal heart rate is heard most clearly at the fetal back. In a cephalic presentation, the fetal heart rate is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus. Reference: Chapter 14: Nursing Management During Labor and Birth - Page 472

Which condition is associated with impaired immunity relating to the aging client? A. Increase in humoral immunity B. Breakdown and thinning of the skin C. Increase in peripheral circulation D. Decrease in inflammatory cytokines

B. Breakdown and thinning of the skin Explanation: The aging process stimulates changes in the immune system. Age-related changes in many body systems also contribute to impaired immunity. Changes such as poor circulation, as well as the breakdown of natural mechanical barriers such as the skin, place the aging immune system at even greater disadvantage against infection. As the immune system undergoes age-associated alterations, its response to infections progressively deteriorates. Humoral immunity declines and the number of inflammatory cytokines increase with age. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 35: Assessment of Immune Function, p. 1015. Chapter 35: Assessment of Immune Function - Page 1015

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply. A. Type of health care facility B. Communication ability C. Mobility D. Developmental level E. Community population

B. Communication ability C. Mobility D. Developmental level Explanation: Nurses should be stewards of a safe environment. In order to promote safety and prevent injuries, nurses must be aware of factors that impact the safety of clients. Some of those factors include the client's developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state. The community's population and the type of facility that the client is in should not impact the safety of the client. Reference: Chapter 27: Safety, Security, and Emergency Preparedness - Page 752

An 8-year-old male child is being seen for a well-child visit. His weight at his visit last year was 50 lb (22.7 kg) and his height was 47 in (119 cm). If he is developing normally, which finding will the nurse expect to note this year? A. Weight 62 lb (28.1 kg) B. Height 49.5 in (124 cm) C. The child's weight is seven times his birth weight. D. The child has all of his adult teeth present.

B. Height 49.5 in (124 cm) Normal physical growth for school-age children is a gain in height of 2.5 inches (6.25 cm) each year. Thus, a height of 49.5 in (124 cm) would be expected growth. The growth in weight is not within normal parameters as this is a 12 lb (5.4 kg) weight gain. A 7-year-old child, not 8-year-old child, should weigh seven times his birth weight. Adult teeth do not normally come in until age 10 to 12. Reference: Chapter 28: Growth and Development of the School-Age Child - Page 1008

The nurse is presenting an in-service on the types of playing that children may engage in. The nurse determines the session is successful when the attending nurses correctly choose which example as representing cooperative play? A. Playing together in an activity without organization. B. Playing in an organized group with each other. C. Playing apart from others without being part of a group. D. Playing independently and are side-by-side.

B. Playing in an organized group with each other. Explanation: During cooperative play, children play in an organized group with each other as in team sports. Solitary independent play means playing apart from others without making an effort to be part of the group or group activity. Associative play occurs when children play together and are engaged in a similar activity but without organization, rules, or a leader, and each child does what she or he wishes. Parallel play occurs when the toddler plays alongside other children but not with them. Reference: Chapter 27: Growth and Development of the Preschooler - Page 995

A client asks the health care provider if any technology exists to limit faulty gene activity from producing unwanted disease proteins. The best response would be: A. DNA forensic testing B. RNA interference C. Translation D. Gene cloning

B. RNA interference Explanation: Scientists are approaching faculty gene activity with the use of RNA interference (RNAi) to stop genes from making unwanted disease proteins. DNA forensic testing is being utilized to solve criminal cases. Gene cloning and translation do not assist with stopping faulty gene activity. Reference: Chapter 4: Genetic Control of Cell Function and Inheritance - Page 73

The nurse is caring for a 4-year-old child during a well-child visit. According to the Sullivan's stages of development, which behavior would the nurse expect to find in this child? A. The child expresses individual views and ideas to the child's parents. B. The child performs actions to earn praise from parents. C. The child may prefer to be in the mother's lap. D. The child spends more time with friends than family.

B. The child performs actions to earn praise from parents. Explanation: According to Sullivan's life stages, this child is in the childhood stage. During this stage, children look at their parents as sources of praise and appreciation. If the child is in the infant stage (0-language), the child's primary need is to have bodily contact and tenderness and would most likely prefer to sit in the mother's lap. The preadolescent child (8-12 years) tends to move away from family as the primary satisfaction in the relationship and start making friends. In the juvenile stage (5-8 years), the child learns to negotiate individual needs. Expressing views and ideas to the parents begin at this age. Reference: Chapter 3: Psychosocial Theories and Therapy - Page 45

In one family, a son was born with polydactyly toes while his sister had polydactyly fingers. In explaining this phenomenon in genetic terms to the parents, which concept should be addressed? A. Heterozygote dominant trait B. Variable expressivity of a gene C. Aneuploidy of genes in all cells D. Deficiencies in enzyme synthesis

B. Variable expressivity of a gene Autosomal dominant disorders are characterized by variable gene penetrance (degree to which the trait is displayed) and expression (differences in how the trait is displayed). Aneuploidy is not a single-gene disorder and does not follow the Mendelian pattern of inheritance. Deficiencies of enzyme synthesis are common in autosomal recessive disorders.X-linked inheritance can be dominant or recessive, but it is not autosomal. Reference: Chapter 5: Genetic and Congenital Disorders - Page 77

A postpartum client is adapting to her new maternal role. She tells the nurse "I am so glad my baby is becoming their own little person." The nurse concludes that the mother is in what phase? A. taking-hold phase B. letting-go phase C. taking-in phase D. dependent phase

B. letting-go phase Explanation: Rubin identified three phases during which a woman adapts to the maternal role. During the taking-in (dependent) phase, which usually lasts 1 to 2 days after childbirth, the client usually is exhausted and dependent on others, focusing on her own needs. During the taking-hold (dependent-independent) phase, which may last from 3 days to 8 weeks, the client vacillates between seeking nurturing and acceptance for herself and seeking to resume an independent role. During the letting-go (interdependent) phase, the client begins to accept the neonate as an individual who's separate from herself. Remediation: Rooming-In For Neonates

A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called? A. letting-go phase B. taking-in phase C. taking-over phase D. taking-hold phase

B. taking-in phase Explanation: The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of caring for the neonate while still fatigued from childbirth. Taking-hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. During the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression may occur during this stage. Remediation: Parent-Infant Bonding

The parent of a 14-year-old adolescent states to the nurse that the adolescent is moody, shuts oneself in the bedroom, and fights with a younger sibling. Which comment is most helpful to support the parent? A. "Set some rules for family etiquette." B. "This is normal for the age." C. "Calmly talk to your adolescent about your concerns." D. "Take away all of the adolescent's privileges until your adolescent starts acting better."

C. "Calmly talk to your adolescent about your concerns." Families and parents of adolescents experience changes that require adjustments and the understanding of adolescent development. The adolescent is striving for self-identity and increased independence. Thus, getting the parent and adolescent talking and sharing information is the most helpful advice. Telling the parent that this is normal does nothing for the family situation. Setting rules will likely alienate the adolescent, and taking away privileges will likely cause conflict between the parent and adolescent. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 29: Growth and Development of the Adolescent, p. 1082. Chapter 29: Growth and Development of the Adolescent - Page 1082

The parents of a newborn diagnosed with a chronic illness ask the nurse, "How will this effect our newborn's growth and development?" Which nursing response is most appropriate? A. "Growth and development will be measured and discussed at each appointment." B. "There is no way to tell about your newborn's growth and development at this young age." C. "It is common for newborn with chronic illnesses to grow and develop at a slower pace." D. "Your newborn will likely need intensive therapy to be able to function with limited assistance."

C. "It is common for newborn with chronic illnesses to grow and develop at a slower pace." Explanation: The nurse would educate the parents regarding growth and development in newborn with chronic illness. The nurse would not give information that is yet to be known. Growth and development is assessed at each appointment; however, this does not provide specific information. Telling the parents there is no way to know about the newborn's growth and development does not provide any information. Reference: Chapter 34: Caring for the Special Needs Child - Page 1194

TA neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate? A. "This is likely just coincidence." B. "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth." C. "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." D. "Neonates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth." E. "You are older now and that can impact how your neonate adapts to the birth process."

C. "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." Explanation: During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon. Reference: Chapter 17: Newborn Adaptation - Page 583

The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age? A. 22 weeks B. 24 weeks C. 20 weeks D. 18 weeks

C. 20 weeks Some clients will not seek early prenatal care, especially if it is not their first pregnancy. The uterus expands to reach the height of the umbilicus by week 20. Before week 20 it is too low to be palpated, and after week 20 it may be beyond the umbilicus. Reference: Chapter 12: Nursing Management During Pregnancy - Page 396

Which nurse is most likely to experience the greatest amount of stress related to his or her position as a nurse? A. A nurse with 10 years of experience working as a nurse educator B. A nurse who is an editor of a nursing journal C. A graduate nurse working on a telemetry unit D. A nurse with 2 years of experience working on an oncology unit

C. A graduate nurse working on a telemetry unit Explanation: Stress is the body's way of responding to any kind of demand or threat. Stress is often greater for new graduate nurses and nurses who work in settings such as an intensive care unit and emergency care. A nurse with 2 or 10 years has less stress because over time the nurse learns to use knowledge and skills learned to care for a variety of clients. A nurse who is an editor of a nursing journal is also a nurse with clinical experience and is now transitioning into a nursing office job. Reference: Chapter 42: Stress and Adaptation - Page 1670

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant? A. Apgar score B. Braden scale C. FLACC scale D. FACES scale

C. FLACC scale Explanation: The FLACC scale (face, legs, activity, cry, and consolability) is used to measure pain for children between the ages of 2 months and 7 years. The Braden scale is used to predict pressure sore risk. The FACES scale is used to assess pain in older children using a series of faces, ranging from a happy face to a crying face. Apgar score is done at birth to assess how well the baby tolerated the birthing process. Reference: Chapter 35: Comfort and Pain Management - Page 1247

Which characteristic of genetic disorders involves a single-gene trait? A. Multifactorial gene mutations B. Abnormal numbers of chromosomes C. Mendelian patterns of inheritance D. Chromosome rearrangements

C. Mendelian patterns of inheritance Explanation: Single-gene disorders are characterized by patterns of transmission that follow the Mendelian patterns of inheritance. Multifactorial inheritance--> involves more than one gene mutation, rearrangement of groups of genes, and uneven numbers of some chromosomes in each cell. Reference: Chapter 5: Genetic and Congenital Disorders - Page 76

A family that consists of two homosexual parents and three children living in the same house is an example of which type of family? A. Extended B. Blended C. Nuclear D. Single-parent

C. Nuclear Explanation: The nuclear family--> is also known as the traditional family and is composed of two parents and their children. The parents might be heterosexual or homosexual, are often married or in a committed relationship. An extended family--> includes aunts, uncles, and grandparents. A blended family is also a traditional family formed when parents bring unrelated children from previous relationships together to form a new family. A single-parent family involves one parent and may be the result of marital separation or divorce, the death of a spouse, or the parent never having been married. Reference: Chapter 4: Health of the Individual, Family, and Community - Page 71

A 76-year-old man is recovering from a myocardial infarction. In regards to his recovery, it is important for the nurse to: A. instruct him to eliminate sex for 1 month. B. have a male counterpart address sexuality. C. address any questions about sexuality. D. refer the client to a therapist.

C. address any questions about sexuality. Explanation: With regard to sexuality, the nurse should spend time with the older adult; use clear, easy-to-understand language; help the client feel more comfortable talking about sex; be open minded and talk openly; listen, and encourage discussion; give advice or suggestions as needed; and understand that sex is not just for the young. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 430. Chapter 23: The Older Adult - Page 430

A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that fetal movement can be felt beginning at which time? A. between 10 and 12 weeks' gestation B. between 24 and 26 weeks' gestation C. between 18 and 20 weeks' gestation D. between 21 and 23 weeks' gestation

C. between 18 and 20 weeks' gestation Explanation: A primigravid can usually detect fetal movements (quickening) between 18 and 20 weeks' gestation. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. Remediation: Obstetric Triage Of Patients

A newborn is born with hypothyroidism. If it is not recognized and treated, what complication is likely? A. dehydration B. blindness C. cognitive impairment D. muscle spasticity

C. cognitive impairment Explanation: A newborn with congenital hypothyroidism is lethargic, hypotonic and irritable. Delayed growth is seen as well as decreased mental responsiveness. The newborn has an enlarged tongue and poor sucking ability. Without treatment with the thyroid hormone, the newborn will develop a cognitive impairment and failure to thrive. Blindness, muscle spasticity and dehydration are not symptoms or complications of the disease. Reference: Chapter 48: Nursing Care of the Child With an Alteration in Metabolism/Endocrine Disorder - Page 1790-1791

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? A. red blood cells: 3,500,000/uL B. white blood cells: 5,000/mm3 C. hemoglobin: 17.5 g/dl D. platelets: 600,000/uL

C. hemoglobin: 17.5 g/dl Explanation: Hemoglobin typically ranges from--> 16 to 20 g/dl. White blood cells are initially elevated soon after birth as a result of birth trauma, typically ranging from--> 10,000 to 30,000/mm3. The newborn's platelet count is the same as that for an adult, ranging between--> 100,000 and 300,000/uL. After birth, the red blood cell count gradually increases as the cell size decreases. Normal count ranges from 5,100,000 to 5,800,000/uL. Reference: Chapter 17: Newborn Adaptation - Page 582

When planning how to respond to a 3-year-old child about telling stories ("tall tales"), the nurse would base the statement on the fact that: A. preschoolers have a limited vocabulary. B. a preschooler is in an insecure period. C. imagination in a 3-year-old is at its peak. D. a 3-year-old knows the word two but not the concept of two.

C. imagination in a 3-year-old is at its peak. Preschoolers have vivid imaginations and love to play "make believe." They are inquisitive learners. It is not unusual for their imaginations to create "tall tales" and be in a world of make-believe. Preschoolers have a vocabulary of between 1,500 and 2,100 words, depending upon their age. They can count to 10 and know at least four colors. Their communication is concrete. At this age they are not capable of abstract thought. During the preschool years, the child develops a sense of identity. They know who they are and to the family in which they belong. They develop the knowledge of right and wrong. The preschool years help develop a child's sense of belonging and his or her place in the world. Reference: Chapter 27: Growth and Development of the Preschooler - Page 993-994

A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which important area should the nurse address during assessment of the client? A. whether sex was consensual B. options for birth control in the future C. knowledge of child development D. sexual development of the client

C. knowledge of child development Explanation: The nurse should address the client's knowledge of child development during assessment of the pregnant adolescent client. The nurse need not address the sexual development of the client or whether sex was consensual. This would not be an opportune time to discuss birth control methods to be used after the pregnancy. Reference: Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 748

A 4-year-old child is admitted to the hospital for surgery. The nurse applies interventions to address what major stressor for a child of this age? A. fear of pain B. fear of bodily injury C. separation from family D. loss of control

C. separation from family Explanation: For infants through preschoolers, separation from the family is the major stressor posed by hospitalization. To minimize the effects of separation, the nurse may suggest that a family member stay with the child as much as possible. Reducing this stressor may help a young child withstand other possible stressors of hospitalization, such as fear of bodily injury, loss of control, and fear of pain. Remediation: Developmental Considerations In Caring For Children: Preschoolers

A nurse is providing anticipatory guidance to the parents of a 2 1/2-year-old girl. To foster the development of autonomy, which instruction would the nurse include? A. "Encourage her to do things that are beyond her skill level." B. "Be sure to reprimand her for seeking out new things." C. "Allow the child to explore the why about things." D. "Encourage the child to dress herself."

D. "Encourage the child to dress herself." Explanation: As motor and language skills develop, the toddler (ages 1 to 3 years) learns from the environment and gains independence through encouragement from caregivers to feed, dress, and toilet self. If the caregivers are overprotective or have expectations that are too high, shame and doubt, as well as feelings of inadequacy, may develop in the child. Confidence gained as a toddler allows the preschooler (ages 4 to 6 years) to take the initiative in learning so that the child actively seeks out new experiences and explores the how and why of activities. If the child experiences restrictions or reprimands for seeking new experiences and learning, guilt results, and the child hesitates to attempt more challenging skills in motor or language development. Reference: Chapter 21: Developmental Concepts - Page 516

The parents of a newborn are deciding if they want their newborn circumcised. The parents ask the nurse if their newborn can feel any pain during the procedure. How should the nurse respond? A. "Your newborn's nervous system is not developed enough to experience pain." B. "I am sure your newborn is too young to experience any pain." C. "Although it is possible for your newborn to experience pain, it is very unlikely for the pain to be intense." D. "It is hard to know for sure, but research shows that it is possible for newborns to experience pain."

D. "It is hard to know for sure, but research shows that it is possible for newborns to experience pain." Explanation: Research has demonstrated that the nervous system structures needed for pain impulse transmission and perception are present before birth (American Medical Association, 2013). Therefore, children of any age, including preterm newborns, are capable of experiencing pain. Reference: Chapter 36: Pain Management in Children - Page 1250

When do most perinatal HIV infections occur? A. Through casual contact B. In utero C. Through breastfeeding D. After exposure during delivery

D. After exposure during delivery Mother-to-child transmission of HIV-1 may occur in utero or through breastfeeding, but most perinatal infections are thought to occur after exposure during delivery. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, p. 1026. Chapter 36: Management of Patients With Immune Deficiency Disorders - Page 1026

A group of nursing students are studying information about childhood cancers in preparation for a class examination. They are reviewing how childhood cancers differ from adult cancers. The group demonstrates understanding of the information when they identify what location as an unlikely site for childhood cancer? A. Kidney B. Blood C. Brain D. Bladder

D. Bladder The most common sites for childhood cancer include the blood, lymph, brain, bone, kidney, and muscle. Bladder is a common site for adult cancer. Reference: Chapter 46: Nursing Care of the Child With an Alteration in Cellular Regulation/Hematologic or Neoplastic Disorder - Page 1684

Which area of the heart that is located at the third intercostal space to the left of the sternum? A. aortic area B. epigastric area C. pulmonic area D. Erb point

D. Erb point Explanation: Erb point is located at the third intercostal space to the left of the sternum. The aortic area is located at the second intercostal space to the right of the sternum. The pulmonic area is at the second intercostal space to the left of the sternum. The epigastric area is located below the xiphoid process. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 689. Chapter 25: Assessment of Cardiovascular Function - Page 689

A nurse is educating a group of middle-aged adults on aging. What information should the nurse include in the teaching? A. As an older adult, you will not be able to learn new skills or knowledge. B. Most older adults reside in a long-term care facility. C. A decline in sexual activity is a normal occurrence as you age. D. How old you feel will be determined by your physical and cognitive abilities.

D. How old you feel will be determined by your physical and cognitive abilities. The physical health and cognitive abilities of older adults are directly related to quality of life and how "old" one really feels. Older adults can maintain healthy sexual activity and are able to learn new skills and knowledge. Of older adults, 90% live in the community, not in long-term care facilities. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 11: Health Care of the Older Adult, p. 205. Chapter 11: Health Care of the Older Adult - Page 205

During embryonic development, which structure develops into the central nervous system (CNS)? A. Neural crest cells B. Notochord C. Ectoderm D. Neural tube

D. Neural tube During embryonic development, the neural tube develops into the CNS, whereas the notochord becomes the foundation around which the vertebral column ultimately develops. As the neural tube closes, ectoderm cells called neural crest cells migrate away from the dorsal surface of the neural tube to become progenitors of the neurons and supporting cells of the parasympathetic nervous system. The surface ectoderm separates from the neural tube and fuses over the top to become the outer layer of skin. Reference: Chapter 13: Organization and Control of Neural Function - Page 314-315

Students preparing for a test are reviewing the structure and function of the male reproductive system. They demonstrate understanding of the material when they identify which of the following as the site of spermatogenesis? A. Prostate gland B. Seminal vesicles C. Vas deferens D. Testes

D. Testes Explanation: The testes--> are responsible for producing sperm (spermatogenesis). The vas deferens--> are the tubes that carry the sperm from the testicles and epididymis to the seminal vesicles, which acts as the reservoir for testicular secretions. The prostate gland--> produces a secretion that is chemically and physiologically suitable to the needs of the sperm in their passage from the testes. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Anatomic and Physiologic Overview, p. 1753. Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders - Page 1753

Preschoolers exhibit sexual curiosity. This builds the preschooler's: A. cognition. B. self-efficacy. C. ideal self. D. self-concept.

D. self-concept. Self-concept--> continues to develop actively during preschool years. Preschoolers' sense of self becomes more defined as they realize that they are separate and unique. During this stage of development, children exhibit great sexual curiosity. Reference: Chapter 41: Self-Concept - Page 1638

A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3750 g) at birth. Weight now is 20 pounds 8 ounces (9300 g). The nurse determines: A. the weight assessment is blatantly inaccurate. B. the child weighs more than expected for age. C. the child weighs the expected amount for age. D. the child weighs less than expected for age.

D. the child weighs less than expected for age. Birth weight should triple by 12 months. The child should weigh near 24 pounds 12 ounces (11250 g). The child is underweight for age. Reference: Chapter 25: Growth and Development of the Newborn and Infant - Page 924

The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range? A. no more than 0.25 mg B. 0.5 to 1.0 mg C. 2.0 to 2.5 mg D. 1.25 to 1.75 mg

B. 0.5 to 1.0 mg Explanation: The efficacy of vitamin K in preventing early vitamin K deficiency bleeding is firmly established and has been the standard of care since the American Academy of Pediatrics (AAP) recommended it in the early 1960s. The AAP (2019) recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg. Reference: Chapter 18: Nursing Management of the Newborn - Page 607

The nurse is caring for Amy, a 10-year-old, who is admitted for a fractured wrist (suffered during a soccer game) repair. She talks a lot about how well she is doing in school this year and her mother agrees. The nurse is assessing her developmental health and knows that Amy is well on the way to achieving which of the following according to Erik Erikson? A. Initiative B. Industry C. Identity D. Trust

B. Industry Explanation: The school-aged child is in the industry-versus-inferiority stage of Erikson's theory, with the child focused on learning useful skills and thereby developing positive self-esteem. Trust is achieved as an infant, initiative is achieved as a preschooler, and identity is achieved as an adolescent. Reference: Chapter 22: Conception through Young Adult - Page 545

A 4-year-old child is drawing with crayons. Which creation by the child would most be reflective of the anticipated skill level of this age? A. The child draws random lines on the paper and reports it is a person. B. The child draws a person with 6 body parts. C. The child is able to proficiently draw several letters of the alphabet. D. The child is able to draw shapes such as circles and squares.

D. The child is able to draw shapes such as circles and squares. Preschool children are creative and like to draw. They are able to draw shapes such as circles and squares. Drawing a figure with at least 6 body parts and writing letters are the expected skills of a 5-year-old. Random lines would be demonstrated by a younger child. Reference: Chapter 27: Growth and Development of the Preschooler - Page 987

The pregnant young adult asks the nurse when she will be able to hear the fetal heart beat. Which is the nurse's best response? A. "Only the health care provider is able to hear the fetal heart beat until late in the pregnancy." B. "You will not be able to hear the heart beat until halfway through your pregnancy." C. "Let's see if we can hear the heart beat today at 8-weeks-gestation." D. "At your 12-week appointment, you will be able to hear the heart beat by Doppler."

D. "At your 12-week appointment, you will be able to hear the heart beat by Doppler." The fetal heart beat is audible by Doppler by 12-weeks-gestation. The client will be able to hear the heart beat at an appointment around 12 weeks of pregnancy. Reference: Chapter 22: Conception through Young Adult - Page 527

When collecting data on a preschool-aged child during a well-child visit, the nurse discovers the child has gained 12 lb (5.4 kg) and grown 2.5 inches (6.3 cm) in the last year. The nurse interprets these findings to indicate which situation? A. Weight is above an expected range and height is within an expected range. B. Weight falls within an expected range and height is less than what would be expected. C. Weight and height are within expected patterns of growth. D. Weight is below an expected range and height is above an expected range.

A. Weight is above an expected range and height is within an expected range. The preschool period is one of slow growth. The child gains about 4 to 5 lb each year (1.4 to 2.3 kg) and grows about 2.5 inches (6.3 cm). The child's weight is above the expected gain and the height is what would be expected. Reference: Chapter 27: Growth and Development of the Preschooler - Page 984

The nurse recognizes that if the infant is following normal development, the infant will be able to focus and follow an object with the eyes by what age? A. 1 month of age B. 21 days of age C. 7 days of age D. 2 months of age

D. 2 months of age Explanation: Newborns are born nearsighted. They prefer the human face to other objects. At 1 month they can recognize by site the people they know. By 2 months of age, the infant can focus and follow an object with the eyes. Binocularity develops at 6 months and color vision follows at 7 months. Reference: Chapter 39: Nursing Care of the Child With an Alteration in Sensory Perception/Disorder of the Eyes or Ears - Page 1378

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding? A. 80 to 100 breaths/min B. 60 to 80 breaths/min C. 12 to 20 breaths/min D. 30 to 60 breaths/min

D. 30 to 60 breaths/min When assessing the respiratory rate of an infant less than 1 month of age, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or adults when they are at rest. Reference: Chapter 25: Vital Signs - Page 645

A mother brings her 18-month-old child to the clinic because the child eats ashes, crayons, and paper. Which information would be most important to obtain about this toddler? A. whether the toddler is eating a soft, low-roughage diet B. whether the toddler is experiencing changes in the home environment C. whether the toddler is experiencing a growth spurt whether the toddler is currently cutting large teeth

B. whether the toddler is experiencing changes in the home environment It is important to determine if the child is experiencing any change in the home environment that could cause anxiety that is relieved through oral gratification. A craving to eat nonfood substances is known as pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica, but research has not substantiated this theory.Pica is unlikely to be caused by the growth spurts, the cutting of large teeth, or soft, low-roughage diets. Remediation: Physical Assessment, Pediatric

A 6-year-old client who has been diagnosed with autism spectrum disorder would be expected to display which behavior? A. The client has multiple motor tics and several vocal tics. B. The client has an irresistible urge to pull out the client's own hair. C. The client spends time alone and shows little interest in making friends. D. The client becomes overly attached to those around the client.

C. The client spends time alone and shows little interest in making friends. Explanation: Children with autism develop language slowly or not at all. They may use words without attaching meaning to them or communicate with only gestures or noises. They spend time alone and show little interest in making friends. Approximately 80% of people with autism also are classified as intellectually disabled. Their most distinctive feature, however, is their seeming isolation from the world around them. This detachment and aloofness help distinguish people with autism from those who are solely diagnosed as intellectually disabled. Reference: Chapter 22: Neurodevelopmental Disorders - Page 423

A nurse is teaching a "care of the infant" class and Kelly, one of the members, asks a question about how long her baby will be considered an "infant". Which of the following is the nurse's best response? A. "From 1 month to 1 year" B. "From conception to 1 year" C. "From birth to 1 year" D. "From birth to 24 months"

A. "From 1 month to 1 year" Explanation: The neonate becomes an infant at 1 month, a period lasting until the first birthday. Infants are one month to one year. Toddlers are one year to three years. The perinatal period is from conception to 1 year. Reference: Chapter 22: Conception through Young Adult - Page 531

On an Apgar evaluation, how is reflex irritability tested? A. raising the infant's head and letting it fall back B. flicking the soles of the feet and observing the response C. tightly flexing the infant's trunk and then releasing it D. dorsiflexing a foot against pressure resistance

B. flicking the soles of the feet and observing the response Explanation: Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose. Reference: Chapter 18: Nursing Management of the Newborn - Page 601

According to Fowler's theory, who or what initiates the development of faith in the infant? A. siblings B. daycare activities C. primary caregivers D. church attendance

C. primary caregivers Explanation: During the prestage of faith development, called undifferentiated faith, trust, courage, hope, and love compete with threats of abandonment and inconsistencies in the infant's environment. The strength of faith at this stage is based on the infant's relationship with primary caregivers. Reference: Chapter 21: Developmental Concepts - Page 520-521

A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate? A. "Neonates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth." B. "This is likely just coincidence." C. "You are older now and that can impact how your neonate adapts to the birth process." D. "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth." E. "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs."

E. "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." Explanation: During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon. Reference: Chapter 17: Newborn Adaptation - Page 583

The client is a 76-year-old who reports difficulty falling asleep and daytime drowsiness. Which figure best reflects REM and NREM cycles of this client?

Explanation: Older adult clients tend to have greater difficulty falling asleep and more frequent awakenings which result in daytime drowsiness. This is best reflected in Answer D. Reference: Chapter 34: Rest and Sleep - Page 1203-1204-1205-1206

The nurse is caring for a preterm infant who requires a heel stick to obtain a blood sample. Which action by the nurse demonstrates a lack of understanding regarding pain in infants? A. assessing for a drop in oxygen saturation as an indicator of pain in this infant B. assessing for chin quivering in this infant as it can be an indicator of pain C. encouraging nonnutritive sucking because this infant is likely to experience pain at a greater intensity D. attempting the heel stick when the infant is asleep to minimize long-term effects of pain

D. attempting the heel stick when the infant is asleep to minimize long-term effects of pain Explanation: Research suggests that preterm infants experience pain at a greater intensity than older children or even adults. The reason for this may be that the inhibitory mechanisms higher in the central nervous system have not had time to develop. In preterm and term newborns, behavioral and physiologic indicators are used for determining pain. Behavioral indicators include facial expression (such as brow contracting and chin quivering) and physiologic signs include changes in oxygen saturation levels. Repeated exposure to painful procedures and events can have long-term consequences and infants feel pain and at a greater intensity regardless if they are sleeping. Sleeping can also be a coping mechanism for the child in pain. Reference: Chapter 36: Pain Management in Children - Page 1248

Which client will have more adipose tissue and less fluid? A. An infant B. A woman C. A man D. A child

B. A woman Explanation: Women have a lower fluid content because they have more adipose tissue then men. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

The mother of a preschooler finds a broken plate in her kitchen floor and asks the child what happened. The child tells the mother that her imaginary friend Lulu dropped it when she was getting it out of the cabinet. How should the mother interpret this fabrication? A. The child feels guilty and wants to pass the blame to someone else. B. Blaming an imaginary friend for accidents is normal behavior for this age group. C. Telling the mother that an imaginary friend did it is concerning and the child needs to be evaluated. D. The child is lying to cover up her wrongdoing to avoid punishment.

B. Blaming an imaginary friend for accidents is normal behavior for this age group. Explanation: Children this age often have imaginary friends to play with and may blame the friend for accidents or other occurrences in the home that they may have caused. This should not be interpreted as intentionally lying or abnormal but rather normal preschool behavior.

During a well-child visit, the caregiver expresses concern that the 3-year-old child often stutters when speaking. Which response should the nurse prioritize to best assist this family? A. "Stuttering is usually indicative of a hearing loss." B. "Children of this age may stutter while they search for just the right word." C. "Stuttering is common in young children because they are not physically capable of forming all the sounds." D. "Difficulties with speaking generally indicate that the adults in the child's life are not reading to the child enough."

B. "Children of this age may stutter while they search for just the right word." Between ages 3 and 5, language development is generally rapid. Most 3-year-old children can construct simple sentences, but their speech has many hesitations and repetitions as they search for the right word or try to make the right sound. Stuttering can develop during this period but usually disappears within 3 to 6 months. Physical capability, hearing loss, or lack of being read to are not reasons stuttering occurs. Reference: Chapter 27: Growth and Development of the Preschooler - Page 988

A nurse is working in a pediatric clinic. The parent has brought in the 2-year-old toddler for a well-child checkup. The parent asks what the common health problems are common for this age. The nurse's correct reply includes which of the following? A. Lice infestation B. Accidents C. Food allergies D. Scoliosis

B. Accidents Accidents are a major health concern for toddlers due to their mobility and exploration of their environment. Food allergies are a common health concern during infancy. Scoliosis and lice infestation are more commonly seen in school-age children. Reference: Chapter 21: Developmental Concepts - Page 512

The nurse is preparing to administer ear drops to a 2-year-old client with an infection of the external auditory canal. The order reads, "2 drops in the right ear three times per day." Which steps should the nurse take to administer this medication? Select all that apply. A. Lie the child on the right side with the left ear facing up. B. Warm the medication to the body temperature. C. Gently pull the pinna up and back and instill the drops into the external ear canal. D. Examine the ear canal for drainage. E. Wash hands and arrange supplies at the bedside.

B. Warm the medication to the body temperature. D. Examine the ear canal for drainage. E. Wash hands and arrange supplies at the bedside. Explanation: The nurse should prepare to instill the eardrops by washing hands, gathering supplies, and arranging the supplies at the bedside. To avoid adverse effects resulting from eardrops that are too cold (such as vertigo, nausea, and pain), the medication should be warmed to body temperature in a bowl of warm water. Temperature of the drops should be tested by placing a drop on the wrist. Before instilling the drops, the ear canal should be examined for drainage that may reduce the medication's effectiveness. Because the dose is to be given in the right ear, the child should be placed on the left side with the right ear facing up. For an infant or a child younger than 3 years, gently pull the auricle down and back because the ear canal is straighter in children of this age-group. Remediation: Eardrop Instillation, Pediatric

When developing a care plan for a hospitalized client, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? A. adolescence B. preschool age C. infancy D. school age

B. preschool age Explanation: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.

The school nurse is teaching growth and development in a health class. What should the nurse teach the students about development? A. It centers around an increase in body's size B. It is best defined as intellectual growth C. It is the process of ongoing change D. It is influenced by genetically predisposed alterations

C. It is the process of ongoing change Explanation: Development is the process of ongoing change, reorganization, and integration that occurs throughout life. Growth centers around the physical attainment such as body size and genetically predisposed alterations as well as development which focuses on the psycho social elements including intellectual growth. Reference: Chapter 21: Developmental Concepts - Page 509

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client? A. ventrogluteal site B. dorsogluteal site C. vastus lateralis site D. deltoid site

C. vastus lateralis site Explanation: The vastus lateralis site is most desirable for administering injections to infants and small children, as well as clients who are thin or debilitated with poorly developed gluteal muscles. The dorsogluteal site is avoided in clients younger than 3 years because their gluteus maximus muscle is not sufficiently developed. The ventrogluteal site, however, is safe for children. The deltoid site is the least-used intramuscular injection site because it is a smaller muscle than the others. It is used only for adults because the muscle is not sufficiently developed in infants and children. Reference: Chapter 29: Medications - Page 853

A young client has a significant height deficit and is to be evaluated for diagnostic purposes. What could be the cause of this client's disorder? A. adrenal disorder B. thyroid disorder C. parathyroid disorder D. pituitary disorder

D. pituitary disorder Explanation: Pituitary disorders usually result from excessive or deficient production and secretion of a specific hormone. Dwarfism occurs when secretion of growth hormone is insufficient during childhood. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 52: Assessment and Management of Patients With Endocrine Disorders, Anterior Pituitary, p. 1508. Chapter 52: Assessment and Management of Patients With Endocrine Disorders - Page 1508