NCLEX - Infancy to Adolescence -1608
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. 1."Bladder control is usually achieved before bowel control." 2."The child should not be forced to sit on the potty for long periods." 3."The ability of the child to remove clothing is a sign of physical readiness." 4."Waiting until the child is 24 to 30 months old makes the task considerably easier." 5."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."
2."The child should not be forced to sit on the potty for long periods." 3."The ability of the child to remove clothing is a sign of physical readiness." 4."Waiting until the child is 24 to 30 months old makes the task considerably easier." 5."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." Waiting until the child is 24 to 30 months old makes the task considerably easier because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents. Bowel control typically occurs before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness.
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? 1.Assess the parents' body shape and stature. 2.Document these as expected findings for a 3-year-old child. 3.Counsel the parent on appropriate physical activities and exercises. 4.Refer the child and the parents for nutritional counseling related to obesity.
1.Assess the parents' body shape and stature. The most prominent feature of childhood and adolescents is physical growth. Birth weight for infants doubles in 4 to 7 months and triples by the end of the first year of life. Weight quadruples by the end of the second year, and then slows to a steady annual rate of 4.4 to 6 pounds (2.09 to 2.73 kg) of weight gain per year until the adolescent growth spurt. The average weight for a 3-year-old is 32 pounds (14.6 kg). Growth in height remains steady at a yearly increase of 2½ to 3 inches (6.75 to 7.5 cm). The average height for a 3-year-old is 37 ¼ inches (95 cm). This child is above the 100th percentile for height and weight when plotted on the growth charts for males. A strong correlation exists between parent and child with regard to traits such as height, weight, and rate of growth. Most physical characteristics, including shape and form of features, body build, and physical peculiarities are inherited and influence the way in which children grow and interact with their environment. Therefore, the nurse should assess the parents' characteristics for tall, well-proportioned adults. Adequate nutrition is closely related to growth and good health. However, this child is proportional for height and weight. There is no evidence that this child is obese. The child is above the 100th percentile on growth charts, so further assessment is warranted. Counseling on appropriate physical activities and exercise is an appropriate part of wellness education but does not relate to this child's height and weight.
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? 1.Encourage the child's parents to stay with the child. 2.Encourage play with other children of the same age. 3.Advise the family to visit only during the scheduled visiting hours. 4.Provide a private room, allowing the child to bring favorite toys from home.
1.Encourage the child's parents to stay with the child. Although the preschooler may already be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may repeatedly ask when parents will be coming for a visit or may constantly want to call the parents. The option of encouraging the child to play with other children is unrelated to the subject of the question and may not be appropriate for a child at risk for immunocompromise. Advising the parents to visit only during visiting hours will increase stress related to separation anxiety. A private room may be necessary, but this does not alleviate the child's fear
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? 1."You need to discipline the child." 2."This is a normal occurrence following hospitalization." 3."The child probably has developed a urinary tract infection." 4."We will need to discuss this behavior with the primary health care provider."
2."This is a normal occurrence following hospitalization." Regression can occur in a preschooler and is most often caused by the stress of the hospitalization. It is best to accept the regression if it occurs. Parents may be overly concerned about regression and should be told that regression is normal following hospitalization. It is premature to discuss the situation with the primary health care provider. Options 1 and 4 are inappropriate responses to the mother
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? 1."Your toddler is only 2 years old, and you should not be giving him choices. He is too young." 2."Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." 3."Your toddler is still in the stage of trust versus mistrust, and you need to spend more time with him so that he feels more secure." 4."Your toddler is experiencing magical thinking, and with this stage if he says 'no,' he believes you will know he means the opposite."
2."Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." According to Erikson, toddlers are acquiring a sense of autonomy while overcoming a sense of shame and doubt. They are attempting to relinquish their dependence and assert independence, which will be present as negativism in their quest for independence. The word no is a very strong part of their vocabulary. Therefore, the other options are inaccurate. Toddlers can be given very simple choices to achieve autonomy. There is nothing in the question that mentions mistrust. Magical thinking refers to cognitive development.
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? 1."I should not force feed my child." 2."I should limit juice to 6 ounces per day." 3."I should feed my child if she will not eat." 4."I should limit snacks to two nutritious ones per day and give them only at my toddler's request."
3."I should feed my child if she will not eat." Toddlers have the skills required to feed themselves. Children who can feed themselves should not be fed or force fed. To increase nutritious intake, juice intake is limited to 6 ounces per day, and milk intake to 16 to 24 ounces per day. In addition, the nurse instructs the mother to limit nutritious snacks to two per day and to give them only at the toddler's request.
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? 1."I will begin offering solids between 4 and 6 months of age." 2."I will introduce one new food over several days beginning with cereal." 3."I will start giving home-prepared orange juice when my child is 3 months old." 4."I will wait to introduce meat to the diet until after my child has eaten cereal, fruit, and vegetables."
3."I will start giving home-prepared orange juice when my child is 3 months old." Solids should be introduced over a period of time between the ages of 4 and 6 months. Failure to introduce solids by 6 months of age might prevent the child from accepting solids later. The pattern in which solids are introduced is not important as long as meats are introduced after cereals, fruits, and vegetables. A single food should be consumed several times over a course of several days to determine if the child has an allergy. Home-prepared orange juice should not be given to the infant before 4 to 6 months of age because of the high nitrite level and high risk of allergic reaction.
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. 1.The liver is immature. 2.The lungs are not developed. 3.Cerebral function is not fully developed. 4.The kidneys are smaller than those of adults. 5.The kidneys are less able to excrete medications 6.The neonate has more difficulty retaining body heat.
1.The liver is immature. 5.The kidneys are less able to excrete medications The increased medication sensitivity of neonates and infants is largely a result of the immature state of five pharmacokinetic processes. These include medication absorption, renal medication excretion, hepatic medication metabolism, protein binding of medication, and exclusion of medication from the central nervous system by the blood-brain barrier. It is true that neonates have more difficulty retaining body heat, but that does not affect the potential for toxicity.
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? 1. 14 days 2. 28 days 3. 30 days 4. 45 days
2. 28 days The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. Significant deviations from the 28-day cycle are associated with reduced fertility. The first day of the menstrual period is counted as day 1 of the woman's cycle.
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? 1."Allow the bottle if it contains juice." 2."Allow the bottle if it contains water." 3."Do not allow the child to have the bottle." 4."Allow the bottle during naps but not at bedtime."
2."Allow the bottle if it contains water." A toddler should not be allowed to fall asleep with a bottle because of the risk of dental caries. If the bottle is allowed in bed, it should contain only water.
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? 1.Seat belt 2.Booster seat 3.Rear-facing convertible seat 4.Front-facing convertible seat
2.Booster seat All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age. Infants should ride in a car in a semi-reclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 pounds) and 1 year of age.
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? 1.Uses a fork to eat 2.Holds a cup in one hand 3.Pours own milk into a cup 4.Uses a knife for cutting food
2.Holds a cup in one hand By 2 years of age, the child can hold a cup in one hand and use a spoon well. By the age of 3 to 4 years, the child begins to use a fork. By the end of the preschool period, the child should begin to use a knife for cutting. Pouring liquids into a cup is a skill that requires fine motor development.
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. 1.Large puzzle 2.Nursery mobile 3.Jack-in-the-box 4.Strings of big beads 5.A pastel-colored stuffed animal 6.A mobile that swings and plays music
2.Nursery mobile 6.A mobile that swings and plays music The nursery mobile is recommended for a 1-month-old child because it provides visual stimulation. If it is a musical nursery mobile, it also serves the purpose of providing auditory stimulation. Strings of big beads, stuffed animals, large puzzles, and a Jack-in-the-box are all age-appropriate toys for a child who is 6 to 12 months of age.
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? 1.A small dog as a house pet 2.The water heater set above 120° F 3.Toys with small loose parts in the playroom 4.A gate placed at the stairs of the second floor
3.Toys with small loose parts in the playroom Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouths, which could lead to aspiration and choking. The temperature of the water heater is a concern, but it is not the greatest hazard. The mother should be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure. A small dog as a house pet is not necessarily a hazard.
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? 1.One half the distance between the antecubital fossa and the shoulder 2.One third the distance between the antecubital fossa and the shoulder 3.Two thirds the distance between the antecubital fossa and the shoulder 4.One quarter the distance between the antecubital fossa and the shoulder
3.Two thirds the distance between the antecubital fossa and the shoulder The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values and those that are too large will cause inaccurate low values. The cuff should cover two thirds the distance between the antecubital fossa and the shoulder.
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? 1.Encourage the child to rest and read. 2.Encourage the parents to room-in with the child. 3.Allow the family to bring in favorite computer games. 4.Allow the child to participate in activities with other individuals in the same age group when the condition permits.
4.Allow the child to participate in activities with other individuals in the same age group when the condition permits. Adolescents are not often sure they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety. Ideally, the peer group will support the ill friend. The other options isolate the child from the peer group.
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? 1."Adolescents love to sleep late in the morning." 2."The child shouldn't be staying up so late at night." 3."If the child eats properly, that shouldn't be happening." 4."The child should have a blood test to check for anemia."
1."Adolescents love to sleep late in the morning." The sleep patterns of the adolescent vary some according to individual needs. However, in general, adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school. Options 2, 3, and 4 are incorrect.
When caring for a 3-year-old child, the nurse should provide which toy for the child? 1.A puzzle 2.A wagon 3.A golf set 4.A miniature farm set
2.A wagon Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle, with large pieces only, may be appropriate. A miniature farm set and a golf set may contain items that the child could swallow.
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? 1.The child snaps large snaps. 2.The child builds a tower of two blocks. 3.The child uses a doorknob to open a door. 4.The child puts on simple clothes independently.
3.The child uses a doorknob to open a door. A 24-month-old would be able to use a doorknob to open a door. At age 15 months, the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently.
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? 1.A board game 2.A large puzzle 3.A finger-painting set 4.A coloring book with crayons
1.A board game The school-age child becomes organized, with more direction in play activities. School-age children's interests include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television. The other options are most appropriate for a toddler.
The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage? 1.Gratification of self 2.Beginning of toilet training 3.Tapering off of conscious biological and sexual urges 4.Association with pleasurable and conflicting feelings about the genital organs
2.Beginning of toilet training Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces. Self-gratification relates to the oral stage. Tapering off of conscious biological and sexual urges relates to the latency period. Association with pleasurable and conflicting feelings about genital organs relates to the phallic stage.
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? 1."I should wait until my child is at least 24 months old." 2."I should have my child sit on the potty until my child urinates." 3."I know that my child will develop bowel control before bladder control." 4."I know my child is ready to begin toilet training if my child can walk well."
2."I should have my child sit on the potty until my child urinates." The mother should wait until the child is 24 to 30 months old because this makes the task of toilet training considerably easier. Toddlers of this age are less negative and usually are more willing to control their sphincters to please their parents. Bowel control is usually achieved before bladder control. The child should not be forced to sit on the potty for long periods. The ability to sit, squat, and walk well are physical signs of readiness.
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? 1."At this age, the child may have a bottle at any time." 2."A bottle may be given if the child isn't taking fluids well during the day." 3."You may give the child a bottle if necessary, but if you do, it should contain water." 4."The child may have a bottle at naptime, but it is best not to give a bottle at bedtime."
3."You may give the child a bottle if necessary, but if you do, it should contain water." A child should never be allowed to fall asleep with a bottle because of the risk of bottle-mouth caries. If the bottle is allowed in bed, it should contain only water. The other options are inappropriate responses to the mother.
A pediatric nurse is caring for a hospitalized toddler. The nurse determines that which play activity would be appropriate for the toddler? 1.Listening to music 2.Playing peek-a-boo 3.Hand sewing a picture 4.Playing with a push-pull toy
4.Playing with a push-pull toy The toddler has increased use of motor skills and enjoys manipulating small objects such as toy people, cars, and animals. Push-pull toys are appropriate for this age. Listening to music is most appropriate for an adolescent. Playing peek-a-boo is most appropriate for an infant. Hand sewing a picture is most appropriate for a school-age child.
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? 1."Avoid a nap during the day." 2."Allow the child to set bedtime limits." 3."Allow the child to have temper tantrums." 4."Inform the child of bedtime a few minutes before it is time for bed."
4."Inform the child of bedtime a few minutes before it is time for bed." Most toddlers take an afternoon nap and until approximately age 2, some also require a morning nap. Toddlers often resist going to bed. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics. Bedtime protests may be reduced by warning the child of bedtime a few minutes before the time
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? 1.The child constantly wants to suck on a pacifier. 2.The child enjoys finger painting on large pieces of paper. 3.The child enjoys sorting blocks according to size and color. 4.The child frequently says "no" when the parents or the nurse asks a question
4.The child frequently says "no" when the parents or the nurse asks a question A 2-year-old child, a toddler, is in the autonomy vs. shame and doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions and exerts him or herself. Trust vs. mistrust characterizes the stage of infancy, and behavior would be constantly sucking on a pacifier for comfort. Initiative vs. guilt characterizes the preschool age. A preschool child would enjoy finger painting. Industry vs. inferiority characterizes the school-age child who would be able to sort blocks, or other items, according to size and color.
he 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? 1.Allow the infant to signal a need. 2.Anticipate all of the needs of the infant. 3.Attend to the crying infant immediately. 4.Avoid the infant during the first 10 minutes of crying.
1.Allow the infant to signal a need. According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, the infant will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others. Therefore, the remaining options are incorrect
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? 1.Animism 2.Egocentric speech 3.Object permanence 4.Global organization
1.Animism Animism means that all inanimate objects are given living meaning. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. Egocentric speech occurs when the child talks just for fun and cannot see another's point of view. Global organization means that if any part of an object or situation changes, the whole thing has changed. Egocentric speech and global organization occur during the preoperational stage.
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? 1.Set limits on the child's behavior. 2.Ignore the child when this behavior occurs. 3.Allow the behavior, because this is normal at this age period. 4.Punish the child every time the child says "no" to change the behavior.
1.Set limits on the child's behavior. According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents" wishes. Saying things like "no" and "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Punishing the child every time the child says "no" is likely to produce a negative response
A 4-year-old child is reluctant to take deep breaths following abdominal surgery. Which measure would be effective to encourage deep breathing? 1.Give the child colorful latex balloons to blow up. 2.Tell the child to exhale forcefully through the peak flowmeter. 3.Administer chest percussion in several postural drainage positions. 4.Have the child pretend to be a big bad wolf blowing the little pig's house down.
4.Have the child pretend to be a big bad wolf blowing the little pig's house down. The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flowmeter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth of respiration.
The nurse is assessing the pain in a 3-year-old child after an appendectomy. Which pain scale should the nurse use? 1.Numeric scale 2.Poker child tool 3.FACES pain rating scale 4.The child is too young to be able to express the pain.
3.FACES pain rating scale There is a pain-rating tool identified with children as young as a neonate. Because the child in this question is 3 years old, the recommended pain scale is the FACES pain scale, which can be used with children as young as 3 years of age. The numeric scale is used with children who can count to 100 by ones. The poker child tool is used beginning with children who are 4 years old.
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? 1.Pre-conventional: Obtaining rewards 2.Pre-conventional: Avoiding punishment 3.Conventional: Obeying rules and regulations 4.Post-conventional: Making and keeping promises
1.Pre-conventional: Obtaining rewards The child is in the pre-conventional stage, and obtaining rewards is the focus of the child's behavior. There is nothing in the question that mentions avoiding punishment. In the later stages of Kohlberg's moral development, a person obeys rules and regulations, and makes and keeps promises.
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? 1.The child is withdrawn. 2.The child is upset with the parents. 3.The child is exhibiting a normal pattern. 4.The child has adjusted to the hospitalized setting.
3.The child is exhibiting a normal pattern. The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home. The parents of hospitalized toddlers are frequently distressed by such behavior. The toddler normally engages in parallel play and plays alongside (but not with) other children. Options 1, 2, and 4 are incorrect.
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? 1."You need to be concerned." 2."You need to monitor the child's behavior closely." 3."You need to praise the child more often to stop this behavior." 4."At this age, the child is developing his or her own personality."
4."At this age, the child is developing his or her own personality." According to Erikson, at ages 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents. Therefore, the other options identify incorrect responses
The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? 1."I know all of my multiplication tables by memory". 2."The ball is gone," when a ball disappears out of sight. 3."I'll use a map to help me find my way in a new town". 4."The moon follows me, and goes to bed when I go to bed"
4."The moon follows me, and goes to bed when I go to bed" In the preoperational stage, the child is demonstrating egocentric thinking by believing the moon's actions revolve around the child. In the sensorimotor stage, a child does not believe an object exists if it is not in sight. A child in the concrete operations stage is able to classify, order, and sort facts, such as the multiplication tables. A child in the formal operations stage is able to solve more complex problems, such as using a map to determine location and directions
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? 1.Move the objects in the child's direct field of vision. 2.Teach the child how to visually scan the environment. 3.Report the observation to the primary health care provider. 4.Provide additional lighting for the child during play activities.
3.Report the observation to the primary health care provider. According to Jean Piaget's theory of cognitive development, it is normal for the infant or toddler not to recognize that objects continue to be in existence, even if out of the visual field; however, this is abnormal for a 6-year-old. If a 6-year-old child does not recognize that objects still exist even when outside the visual field, the child is not progressing normally through the developmental stages. The nurse should report this finding to the health care provider. Options 1, 2, and 4 delay necessary follow-up and treatment.
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? 1.Initiative vs. guilt 2.Industry vs. inferiority 3.Identity vs. role confusion 4.Autonomy vs. shame and doubt
4.Autonomy vs. shame and doubt Negative feelings of doubt and shame arise when individuals are made to feel self-conscious and shame. The positive outcomes of mastering this developmental stage are self-control and willpower. The lasting outcomes of initiative vs. guilt are direction and purpose. Not mastering this stage leads to guilt and lack of purpose. The ego quality developed from a sense of industry is competence. Feelings of inadequacy and inferiority may result from not mastering this task. The outcome of successful mastery of identity vs. role confusion is a sense of personal identity. Inability to solve this conflict results in role confusion.
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? 1.Ask the client to use a numerical rating scale of 0 to 10. 2.Institute the use of a patient-controlled analgesia (PCA) pump. 3.Ask the client to point to faces (smiling to very sad) that best describe the pain. 4.Ask the client to use a word descriptive rating scale (no, little, medium, large, worst pain).
3.Ask the client to point to faces (smiling to very sad) that best describe the pain. A client of preschool age has the level of cognitive ability to recognize happy and sad faces and to correlate them with the level of pain experienced. Using descriptive words to communicate varying intensities of pain may be too complicated for some preschoolers. Some preschool children may not be able to count or understand the value of numbers in relation to other numbers. Children of preschool age are too young to control a PCA pump.
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? 1.Cooing sounds 2.Use of gestures 3.Babbling sounds 4.Interest in sounds
3.Babbling sounds Babbling sounds are common between the ages of 3 and 4 months. Additionally, during this age, crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months
The nurse is caring for a 8-month-old infant. The nurse determines the child is at the expected developmental level if the child displays which behavior? 1.Waves bye-bye 2.Uses gestures to communicate 3.Babbles using single consonants 4.Uses simple words such as "mama"
1.Waves bye-bye Using single-consonant babbling occurs between 6 and 8 months. Between 8 and 9 months the infant begins to understand and obey simple commands such as "wave bye-bye." Using simple words such as "mama" and the use of gestures to communicate begin between 9 and 12 months.
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? 1.Adolescents are moody and act out a lot. 2.Adolescents self-reflect, so withdrawal is normal. 3.Adolescents like to stay up late but rarely have insomnia. 4.Adolescents like the unkempt look and are not concerned about their appearance.
3.Adolescents like to stay up late but rarely have insomnia. The signs of depression include crying spells, insomnia, eating disorders, social isolation and withdrawal, serious acting-out behavior, feelings of hopelessness, unexplained physical symptoms, loss of interest in appearance, and giving away things or possessions. Staying up late is the only option that represents normal adolescent behavior.
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? 1.1200 2.1800 3.2200 4.3000
3.2200 The recommended amount of daily calories for a male adolescent between the ages of 15 and 18 years is 2200. Options of 1200 or 1800 calories would not provide a sufficient number of calories for this adolescent, and the option of 3000 calories is an incorrect number of calories.
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? 1.15 pounds 14 ounces 2.23 pounds 13 ounces 3.31 pounds 12 ounces 4.39 pounds 11 ounces
3.31 pounds 12 ounces By the age of 2½ years, the toddler should have quadrupled his or her birth weight. The child doubles the birth weight by age 5 to 6 months and triples the birth weight by 1 year of age. The correct choice, 31 pounds 11 ounces, is quadruple the birth weight
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? 1.Keeping the infant as quiet as possible 2.Restraining the infant to prevent tubes from being dislodged 3.Placing small toys in the crib to provide stimulation for the infant 4.Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization
4.Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization A 10-month-old is in the trust vs. mistrust stage of psychosocial development, according to Erikson. The infant is developing a sense of self, and the nurse should most appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and to provide sensory stimulation. Placing small toys in the crib is an unsafe action Keeping the child as quiet as possible will not provide sensory stimulation. The infant should not be restrained.
Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory? 1."Individuals move through all six stages in a sequential fashion." 2."Moral development progresses in relation to cognitive development." 3."A person's ability to make moral judgments develops over a period of time." 4."It provides a framework for understanding how individuals determine a moral code to guide his or her behavior."
1."Individuals move through all six stages in a sequential fashion." Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal morality. The other options are correct statements regarding Kohlberg's theory.
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? 1.Blocks 2.A music video 3.A 10-piece puzzle 4.Large picture books
3.A 10-piece puzzle In the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games. Ten-piece puzzles are also appropriate and aid with fine motor development. Blocks are most appropriate for the toddler. A music video is most appropriate for the adolescent. Large picture books are most appropriate for the infant.
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? 1."The child will withdraw." 2."Separation anxiety is not an issue in a 2-year-old." 3."The child may ignore the parents when they visit." 4."Two-year-olds usually adjust well to hospitalization."
3."The child may ignore the parents when they visit." The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or by pretending to be more interested in play than in going home. Parents of hospitalized toddlers frequently are distressed by such behavior. The toddler engages in parallel play and plays alongside but not with other children.
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? 1.Sensorimotor 2.Preoperational 3.Formal operational 4.Concrete operational
1.Sensorimotor Jean Piaget's first stage of cognitive development is the sensorimotor stage (birth to 2 years). The preoperational stage is the second stage (2 to 7 years of age). The concrete operational stage is the third stage (7 to 11 years of age). The formal operational stage is the fourth stage (11 years of age to adulthood).
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? 1.Sit independently. 2.Build a tower of three blocks. 3.Indicate her wants by pointing. 4.Pull herself up into a standing position.
1.Sit independently. For premature infants, calculate the developmental age by deducting the time of prematurity from the age of the child until reaching the age of 2 years. In this case, subtract 2 months from 1 year to equal 10 months of age. A 10-month-old child can sit independently. By 15 months of age, a child should walk independently and indicate wants by pointing and grunting. By 18 months of age, a child should be able to build a tower of three blocks
Which interventions are appropriate for the care of an infant? Select all that apply. 1.Provide swaddling. 2.Talk in a loud voice. 3.Provide the infant with a bottle of juice at naptime. 4.Hang mobiles with black-and-white contrast designs. 5.Caress the infant while bathing or during diaper changes. 6.Allow the infant to cry for at least 10 minutes before responding.
1.Provide swaddling. 4.Hang mobiles with black-and-white contrast designs. 5.Caress the infant while bathing or during diaper changes. Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to also do so. Additional interventions include playing a music box, radio, or television or having a ticking clock or metronome nearby. Hanging a bright, shiny object within 20 cm to 25 cm of the infant's face in the midline and hanging mobiles with contrasting colors (e.g., black and white) provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk of nursing (bottle-mouth) caries.
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? 1.The child believes the moon follows her. 2.The child can consider her friends' points of view. 3.The child demonstrates the ability to think abstractly. 4.The child is able recognize which animals are mammals.
1.The child believes the moon follows her. A 5-year-old child is in Jean Piaget's preoperational stage of egocentrism, such as believing the moon follows her. Being able to classify and sort facts describes Jean Piaget's concrete operational stage (7 to 11 years of age); thinking abstractly and considering other's points of view describe Jean Piaget's formal operational stage (11 years of age to adulthood).
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? 1."It is best to substitute sweets or snacks with food items such as cheese." 2."Proper dental care is not necessary for toddlers until their permanent teeth erupt." 3."I should schedule my child's first dental examination when his first primary tooth erupts." 4."I do not need to be concerned if my child swallows some toothpaste while he is brushing his teeth."
2."Proper dental care is not necessary for toddlers until their permanent teeth erupt." The nurse should instruct the mother that proper dental care to a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries. The first dental visit should be made after the first primary tooth erupts and no later than 30 months of age. It will not hurt the child if some of the toothpaste is swallowed.
The nurse determines a 5-year-old child is in the expected Erikson's psychosocial stage if the child makes which comment? 1."I like drawing my mommy pictures with my finger paints." 2."My favorite thing to do is having recess at school with my friends." 3."All my friends and I hang around the mall on Saturday mornings." 4."No, mommy, I don't want to take a bath. I don't need to go potty."
1."I like drawing my mommy pictures with my finger paints." A 5-year-old child would be expected to be experiencing Erikson's psychosocial stage of initiative versus guilt (late childhood, 3 to 6 years). A child in this stage enjoys exploring and making art. During Erikson's stage of industry vs. inferiority, which occurs during school age (6 to 12 years), a child spends a great deal of time in school and with friends. Hanging around at the mall describes behaviors that correspond with the stage that occurs during adolescence, identity vs. role confusion. Episodes of negativism best describes Erikson's stage of shame vs. doubt, which occurs during toddlerhood (early childhood, 18 months to 3 years).
The nurse determines an adolescent is showing progress toward completing Erikson's psychosocial developmental stages if the adolescent makes which statement? 1."I can't decide whether or not college is what's best for me." 2."When I look back on my life, I think I've done well, despite my problems." 3."I've met people who like that kind of music and we're going to a concert next week." 4."I believe I have finally met the person I truly would like to spend the rest of my life with."
3."I've met people who like that kind of music and we're going to a concert next week." An adolescent (12 to 20 years) would be expected to be experiencing Erikson's psychosocial stage of identity vs. role confusion. In this stage an adolescent has strong social relationships and makes decisions about likes and dislikes. Not having an idea about the role in the future does not indicate successful progress through the stages. Life review and selecting a life partner are later into the development of the individual and do not occur generally during adolescence.
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? 1.Let the child wear his own clothing when friends visit. 2.Allow the child to have his hair dyed if the parent agrees. 3.Allow the child to play loud music in the hospital room. 4.Allow the child to keep the shades closed and the room darkened at all time
1.Let the child wear his own clothing when friends visit. Adolescents need to identify with their peers and have a strong need to belong to a group. They like to dress like the group and wear similar hairstyles. Because Crutchfield traction uses skeletal pins, hair dye is not appropriate. The boy should be allowed to wear his own clothes to feel a sense of belonging to the group. Loud music may disturb others in the hospital. The boy's request for a darkened room is indicative of a possible problem with depression that may need further evaluation and intervention
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? 1."My child is finally toilet trained." 2."I've noticed my child is developing pubic hair." 3."Yesterday my son asked me why he looked different from his sister." 4."My son hangs around other boys, and they've started saying girls have cooties."
3."Yesterday my son asked me why he looked different from his sister." Freud's phallic stage of development includes the recognition of differences between the sexes. Accomplishing toilet training occurs during the Freud's anal stage. Development of pubic hair is characteristic of the genital stage. Freud's latency stage is characterized by same sex friendships and making comments about the other sex.
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? 1.Egocentric judgment 2.Law-and-order orientation 3.Good boy-nice girl orientation 4.Social contract and legalistic orientation
3.Good boy-nice girl orientation According to Kohlber's theory of moral development, during the good boy-nice girl orientation, the child acts in a way to please other people. Sharing is an example of this behavior. A child in the egocentric judgment stage has no awareness of right or wrong. A person in the law-and-order orientation stage obeys laws to maintain social order. During the social contract and legalistic orientation stage, a person is aware that others may have another set of values and opinions.
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? 1.Egocentric judgment 2.Law-and-order orientation 3.Punishment-obedience stage 4.Good boy-nice girl orientation
3.Punishment-obedience stage Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion, but not everyone reaches stages 5 and 6 during his or her development of personal morality. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It also states that moral development progresses in relation to cognitive development, and a person's ability to make moral judgments develops over a period of time. In stage 1 (ages 2-3 years; punishment-obedience orientation), children cannot reason as mature members of society because they are too young to do so. A child obeys rules to avoid punishment. It is appropriate for a parent to explain limitations, and to provide distractions. In the egocentric stage, an infant has no concept of right or wrong. A child who is in the law-and-order orientation stage obeys laws to maintain social order. In the good boy-nice girl orientation stage, a child behaves in a way to avoid displeasing others
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? 1."Your child is acting like a baby." 2."The doctor will need to be notified." 3."This is common during hospitalization" 4."A 4-year-old is too old for this type of behavior."
3."This is common during hospitalization" In the hospitalized preschooler, it is best to accept regression, such as thumb sucking if it occurs, because it is most often caused by the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home. There is no need to call the health care provider. Telling the parents the child is acting like a baby or being too old to act this way is inappropriate.
