EAQ 1: The Patient Profile
Which source of stress would the nurse anticipate in a 4-year-old child? 1 Attention 2 Confusion 3 Stranger anxiety 4 Separation anxiety
1 Attention is a particular source of stress in 4-year-olds. A child in this age group likes to talk and is frustrated if ignored or put off. Confusion and stranger anxiety are sources of stress in 3-year-olds. Separation anxiety is a source of stress to 3-year-olds and 5-year-olds as well.
At which age would the nurse anticipate the appearance of an imaginary friend for a preschool-age client? 1 3 years old 2 4 years old 3 5 years old 4 6 years old
1 Imaginary friends typically appear by 3 years of age and can last throughout the preschool stage of development. If an imaginary friend has not appeared by this age, it is unlikely to expect this to surface at 4, 5, or 6 years of age.
Which medication treatment in the client during her gestation may cause a single-lobed brain and neural tube defects? 1 Simvastatin 2 Isotretinoin 3 Carbamazepine 4 Cyclophosphamide
1 Neural tube defects and single-lobed brains are teratogenic effects in a newborn associated with simvastatin, an HMG-CoA reductase inhibitor. Isotretinoin may cause central nervous system (CNS) defects. Carbamazepine exposure may cause neural tube defects. Cyclophosphamide may cause CNS malformation as a teratogenic effect.
Which is the primary focus of nursing care in the "family as context" approach? 1 The relationship among family members 2 The health and development of an individual 3 The ability of the family to meet its basic needs 4 The family's process of caregiving for a sick member
2 In the "family as context" approach, the primary focus is the health and development of an individual in a specific environment. The relationship and family processes are the primary focus when the family is viewed as the client. When the family is viewed as the context, the focus is on the ability of the family to meet the basic needs of the individual, not its own needs. The process followed by the family when caring for the sick family member is assessed when the family is viewed as the client.
Which fine motor skills may be observed in an 8- to 10-month-old infant? Select all that apply. One, some, or all responses may be correct. 1 Using pincer grasp well 2 Picking up small objects 3 Showing hand preference 4 Crawling on the hands and knees 5 Pulling oneself to standing or sitting
1,2,3 The fine motor skills evident in 8- to 10-month-old infants include the accurate use of the pincer grasp and picking up small objects. At this stage, infants may also demonstrate a hand preference. Crawling on the hands and knees and pulling oneself to a standing or sitting position are considered gross motor skills.
Which is a common attribute that the nurse assesses in an "easy" child? 1 Passive resistance 2 Predictable habits 3 Intense mood expressions 4 Slow adaptation to change
2 The nurse anticipates that the "easy" child will have predictable habits. Passive resistance is a trait assessed in the "slow to warm up" child. Intense mood expressions and slow adaptation to change are characteristics of the "difficult" child.
Which language developmental milestone is seen in 4-year-olds? 1 Names four or more colors 2 Knows simple songs 3 Has a vocabulary of about 2100 words 4 Uses sentences of six to eight words, with all parts of speech
2 A 4 year old typically knows simple songs. A 5 year old typically can name four or more colors, has a vocabulary of about 2100 words, and uses sentences of six to eight words with all parts of speech.
Which would be included in the plan of care for an obstetrical client who has been taking carbamazepine throughout the first trimester of pregnancy? 1 Evaluation for fetal hydramnios 2 Evaluation for a neural tube defect 3 Evaluation for cardiac malformation 4 Chromosomal assessment for Down syndrome
2 Carbamazepine is associated with neural tube defects. Fetal hydramnios, cardiac malformation, and Down syndrome are not related to the use of carbamazepine.
According to Kohlberg's theory of moral development, which stage is a part of conventional reasoning? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrument relativist orientation 4 Universal ethical principle orientation
2 In Kohlberg's theory, the society-maintaining orientation is stage 4 of conventional reasoning. Social contract orientation is stage 5 of postconventional reasoning. Instrument relativist orientation is stage 2 of preconventional reasoning. Universal ethical principle orientation is stage 6 of postconventional reasoning.
A 10-year-old child has been working on earning all of the scouting badges. Which of Erikson's stages of psychosocial development is this child achieving? 1 Identity 2 Industry 3 Intimacy 4 Initiative
2 The school-aged child is working on industry versus inferiority. A sense of accomplishment is an important part of this stage. Erikson classifies the adolescent as working on the development of identity versus confusion. It occurs as the child becomes independent from parents, creates a sense of self, and develops relationships with others. Intimacy versus isolation is the psychosocial developmental stage of young adulthood, when the security of self-identity changes to the insecurity of trying to establish a close relationship with another person. Initiative versus guilt is the psychosocial developmental stage of preschool children, who strive to seek out new experiences and discover their capabilities.
Which type of play do 2-year-old toddlers engage in? 1 Group 2 Parallel 3 Dramatic 4 Cooperative
2 Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children; starting at the preschool age, they assume and act out roles. Cooperative play is also characteristic of older children; starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peers' needs.
Which genetic syndromes are mostly recognized in adolescence? Select all that apply. One, some, or all responses may be correct. 1 Down syndrome 2 Turner syndrome 3 Edwards syndrome 4 Angelman syndrome 5 Klinefelter syndrome
2, 5 Turner syndrome and Klinefelter syndrome are genetic disorders most commonly recognized in adolescence. Although these syndromes are associated with genetic abnormalities, they may not be detected until adolescence because abnormalities may not become apparent until the client reaches this growth stage. Down syndrome, Edwards syndrome, and Angelman syndrome are recognized in the prenatal to newborn periods.
Which bones are examples of a client's flat bones? Select all that apply. One, some, or all responses may be correct. 1 Sacrum 2 Scapula 3 Sternum 4 Humerus 5 Mandible
2,3 Flat bones such as the scapula and sternum are compact bones separated by a layer of cancellous bone that contains bone marrow. Bones such as the sacrum and mandible are irregular bones; they appear in a variety of shapes and sizes. The humerus is a long bone with a central shaft and two widened ends.
Which school-age client would the nurse anticipate will experience sibling rivalry as a source of stress? 1 A 9-year-old male 2 A 7-year-old male 3 A 6-year-old female 4 An 8-year-old female
3 A 6-year-old school-age client is most likely to experience sibling rivalry as a source of stress. The 9-year-old, 7-year-old, and 8-year-old are not as likely to experience sibling rivalry as a source of stress.
Which physiological changes should be noticed in an adolescent during puberty? Select all that apply. One, some, or all responses may be correct. 1 Increase in the respiratory rate 2 Increase in the number of neurons 3 Increase in number of neural connections 4 Decrease in the basal body temperature gradually 5 Increase in serum iron, hemoglobin, and hematocrit
3,4,5 During puberty, as a part of normal physiological growth, there is proliferation of support cells that nourish the neurons along with increase in number of neural connections in the brain. The basal body temperature decreases gradually and reaches adult value by 12 years of age. The size and strength of heart, blood volume, systolic blood pressure, serum iron levels, hemoglobin, and hematocrit values increase whereas heart rate decreases and reaches adult value. The diameter and length of the lungs increase, but respiratory rate decreases gradually to reach the adult value by adolescence. The growth of neurons does not increase but slows to a more gradual rate by adolescence.
Which tissue connects the client's tibia to the femur at the knee joint? 1 Fascia 2 Bursae 3 Tendons 4 Ligaments
4 A ligament is a dense, fibrous connective tissue that connects bone to bone, such as the tibia to the femur at the knee joint. Ligaments provide stability while permitting controlled movement at the joint. Fascia is a connective tissue that can withstand limited stretching; it provides strength to muscle tissues. Bursae are small sacs of connective tissue lined with synovial membrane and synovial fluid that are located at bony prominences and joints to relieve pressure. A tendon is a dense, fibrous connective tissue that attaches muscle to bone.
The nurse is performing an assessment of fine motor skills on an infant. Which actions would the nurse observe? Select all that apply. One, some, or all responses may be correct. 1 Crawling 2 Creeping 3 Sitting erect 4 Holding a rattle 5 Picking up objects 6 Holding a baby bottle
4,5,6 Holding a rattle, picking up objects, and holding a baby bottle are demonstrations of fine motor skills. Gross motor skills include crawling, creeping, and sitting erect.
Which would be common characteristics of a relationship between a middle adolescent and parents? Select all that apply. One, some, or all responses may be correct. 1 Great push for emancipation 2 Low point in the parent-child relationship 3 Desire to remain dependent on parents 4 Major conflicts over independence and control 5 Emotional and physical separation from parents
1,2,4 A child in middle adolescence will have a great push for emancipation, a low point in the parent-child relationship, and major conflicts over independence and control. A younger child will have a desire to remain dependent on his or her parents. A child in late adolescence will have an emotional and physical separation from his or her parents.
According to Erikson, which would the nurse anticipate when assessing an adolescent? 1 Being engaged in tasks 2 Questioning sexual identity 3 Having highly imaginative thoughts 4 Wanting to participate in organized activities
2 The nurse would anticipate the adolescent to question sexual identity, according to Erikson. Being engaged in tasks and wanting to participate in organized activities is expected for the school-age child. The nurse would anticipate that a preschool-age child would have highly imaginative thoughts.
Identify factors associated with an increased incidence of abuse within a family. Select all that apply. One, some, or all responses may be correct. 1 Acute illness 2 Pregnancy 3 Drug abuse 4 Chronic illness 5 Sexual orientation
2,3,5 Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.
Due to the immature immune systems of a toddler, which would the nurse anticipate when the child attends daycare? 1 Poor appetite 2 Minor infections 3 Temper tantrums 4 Bumps and bruises
2. minor infections Due to a continued immature immune system, the nurse anticipates that the toddler-age client who attends daycare will experience an increase in infection due to exposure to new antigens. A poor appetite and temper tantrums are common during the toddler stage of development; however, these are not due to an immature immune system. The toddler client is at risk for injury (bumps and bruises) due to a lack of motor coordination, not an immature immune system.
Which gestational period would the nurse identify as appropriate for the administration of corticosteroids during preterm labor? 1 Less than 20 weeks 2 20 to 24 weeks 3 24 to 34 weeks 4 More than 34 weeks
3 If preterm labor occurs during 24 to 34 weeks of gestation and if labor is unavoidable, corticosteroids should be administered to promote lung maturity. Labor occurring before 20 weeks of gestation usually results in a nonviable fetus; corticosteroids would not need to be administered. Corticosteroids do not promote lung maturation during 20 to 24 weeks of gestation. Fetal lungs mature at 34 weeks of gestation. A fetus in this period of gestation would not require the administration of corticosteroids if labor is unavoidable.
In which stage of Kohlberg's theory of moral development would the nurse anticipate a client who wants to maintain expectations with his or her immediate group? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4
3 In level II, conventional reasoning, stage 3, the nurse anticipates a client who wants to win approval and maintain expectations of his or her immediate group. In level I, preconventional reasoning, stage 1, the nurse anticipates absolute obedience to authority and rules. In level I, stage 2, the nurse anticipates that the child will realize there is more than one right view. In level II, stage 4, the client expands focus from the relationship with others to societal concerns.
Which quantity of iron would be considered mildly to moderately toxic in a preschool child? 1 8 mg/kg 2 15 mg/kg 3 35 mg/kg 4 65 mg/kg
3 Ingestions of 20 to 60 mg/kg of iron are considered mildly to moderately toxic in children. Ingestion of either 8 mg/kg or 15 mg/kg is not considered toxic. Ingestion of amounts greater than 60 mg/kg (here, 65 mg/kg) is severely toxic and possibly fatal.
Which medication treatment may have been given during gestation to a mother whose baby was born with shortened limbs? 1 Phenytoin 2 Topiramate 3 Thalidomide 4 Carbamazepine
3 Thalidomide is an anticancer medication that may cause shortening of the limbs as a teratogenic effect. Phenytoin, topiramate, and carbamazepine are antiseizure medications that may cause growth delays and neural tube defects.
Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? 1 Shut the client's door during the night. 2 Apply a vest restraint when the client is in bed. 3 Leave a dim light on in the client's room at night. 4 Administer the client's prescribed as-needed sedative medication.
3 The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated by closing the door. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.
A full-term infant who is large for gestational age (LGA) should be monitored for which risk? 1 Hypotension 2 Hypothermia 3 Hypocalcemia 4 Hypoglycemia
4 Infants that are LGA are considered at risk for hypoglycemia, and their glucose should be monitored following a protocol. LGA infants are not at an increased risk for hypotension, hypothermia, or hypocalcemia.
Which would evidence of the Babinski reflex indicate during a newborn assessment? 1 Hypoxia during labor 2 Neurological injury during birth 3 Hyperreflexia of the muscular system 4 Immaturity of the central nervous system (CNS)
4 Stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes (Babinski sign). CNS damage resulting from hypoxia may manifest as a lack of Babinski sign. The newborn would not elicit the Babinski reflex if there were neurological injury during birth. Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinski reflex.
By which age should an infant have had his or her first dental examination? 1 3 months 2 9 months 3 12 months 4 18 months
3 A child will have completed an initial dental visit by the age of 12 months. The initial examination should be completed by age 6 months or within 6 months of the first tooth erupting, which averages at around the age of 12 months.
Identify the stage at which an adolescent develops abstract thinking. 1 Genital stage 2 Conventional reasoning 3 Formal operations period 4 Identity vs. role confusion
3 According to Piaget's moral development theory, an adolescent develops abstract thinking during the formal operations period. According to Freud's genital stage, sexual urges reawaken and are directed to an individual outside the family circle. During the conventional reasoning stage, a person establishes his or her morals based on his or her own personal internalization of societal expectations. According to the identity versus role confusion stage, there is a marked preoccupation with appearance and body image.
