Saunders Developmental Stages

The nurse is preparing to perform an abdominal examination. The initial step should be which?

Inspection Rationale: The appropriate technique for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered. The sequence of maneuvers is inspect, auscultate, percuss, and palpate.

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

Having storytelling hours Rationale: Clients who like to retell stories or to describe past events need to be provided with the opportunity to do so. This phenomenon is called life review or reminiscence. In a sense, it is a way for the older client to relive and restructure life experiences, and it is a part of achieving ego identity.

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

"Adolescents love to sleep late in the morning." Rationale: 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.

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

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

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

"Individuals move through all six stages in a sequential fashion." Rationale: 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. Options 2, 3, and 4 are correct statements regarding Kohlberg's theory.

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?

"It is best to ignore the behavior." Rationale: In the hospitalized preschooler, it is best to accept regression 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.

An older client confides to the visiting nurse the fear of falling while going to the bathroom at night. Which statement indicates an understanding of the visual changes affecting the older client?

"Keep a red light on in the bathroom at night." Rationale: Because it takes longer to adapt to changes from dark to light and vice versa, older people are at greater risk for falls and injuries. Any place where there is a sudden change from dark to light or from light to dark can be dangerous. Getting up during the night is hazardous for an older client. Eyes adapt to the dark by using the rod receptors, which are sensitive to short blue-green wavelengths. Red wavelengths are longer and are perceived by the cones. Thus, a red light in the bathroom at night allows for adequate vision to function in the dark without the need for adaptation.

The nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is which?

"The child has the ability to think abstractly." Rationale: In the formal operations stage, the child has the ability to think abstractly and solve problems.

The parents of a 4-year-old child tell the nurse that they are concerned because the child has been masturbating. Which is the appropriate response by the nurse?

"This is a normal behavior at this age." Rationale: According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.

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

3 Rationale: When auscultating the abdomen, the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are always present here normally. The nurse then proceeds to the other quadrants 1, 2, and 4.

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

A normal psychosocial response According to Erikson, the later years of life are from 65 years of age until death. The adult reminisces about past life experiences, often viewing them in a positive way. The adult needs to feel good about his or her accomplishments, see successes in his or her life, and feel that he or she has made a contribution to society.

The nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss?

A physical obstruction to the transmission of sound waves Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

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

A puzzle Rationale: In the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games. 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.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. The nurse understands that this indicates which finding?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed Rationale: In the Romberg test, the client is asked to stand with the feet together and the arms at the sides and to close the eyes and hold the position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid, twitching of the eyeballs. A positive Babinski test results with dorsiflexion of the ankle and great toe with fanning of the other toes. If this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding in a past pointing test.

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

A wagon Rationale: 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 farm set and a golf set may contain items that the child could swallow.

The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse tells the UAPs that which situation portrays ageism?

Advising older adults to forgo aggressive treatment Rationale: Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different from "me" and will remain different from "me." Therefore, they are portrayed as not experiencing the same desires, needs, and concerns.

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). The nurse explains that which is the best time to perform this exam?

After a shower or bath Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client to select a day of the month and perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. This will provide ease in palpating, and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing the TSE.

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

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

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

Allow the infant to signal a need. Rationale: 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, he or she 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.

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

Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations Rationale: A focused data collection process focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

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

Beginning of toilet training Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces.

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

Choosing his social activities Rationale: Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and choose solutions that allow for continued personal freedom as long as the rights and property of others are not harmed. The loss of autonomy—and, therefore, independence—is a very real fear among older clients. Option 4 is the only choice that allows the client to be a decision maker.

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

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

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

Decreased lean body mass and glomerular filtration rate Rationale: The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate.

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

Document the findings. Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. Therefore, because the findings are normal, the nurse should document the findings.

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. According to Piaget's theory of cognitive development, which behavior is this known as?

Egocentric speech Rationale: 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.

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

Encourage expression of feelings, concerns, and fears. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know that they will not be abandoned by the nurse. Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

While collecting data related to the cardiac system on a client diagnosed with an incompetent heart valve, the nurse auscultates a murmur. Which best describes the sound of a heart murmur?

Gentle, blowing or swooshing noise Rationale: A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. Lubb-dubb sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.

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

Irregular, noisy breathing and cold, clammy skin Rationale: The clinical signs of impending or approaching death include inability to swallow; pitting edema; decreased gastrointestinal and urinary tract activity; bowel and bladder incontinence; loss of motion, sensation, and reflexes; cold or clammy skin; cyanosis; lowered blood pressure; noisy or irregular respiration; and Cheyne-Stokes respirations.

Which are components of Kohlberg's theory of moral development? Select all that apply.

Moral development progresses in relation to cognitive development. A person's ability to make moral judgments develops over a period of time. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. In stage 2 (instrumental relativist orientation), the child conforms to rules to obtain rewards or to have favors returned. Rationale: 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 to 3 years; punishment-obedience orientation), children cannot reason as mature members of society because they are too young to do so. In stage 2 (ages 4 to 7 years; instrumental relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

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

Oral mucosa Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

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

Overall sclerotic lesions Rationale: Sclerotic lesions occur as bone resorption increases and results in replacement of original bone with fibrous material. This condition occurs in Paget's disease, an age-related disorder.

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

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

According to Kohlberg's theory of moral development, at the preconventional level, moral development is thought to be motivated by which factor?

Punishment and reward Rationale: In the preconventional level, morals are thought to be motivated by punishment and reward. If the child is obedient and not punished, then he or she is being moral. The child sees actions as either good or bad. If the child's actions are good, then the child is praised. If the child's actions are bad, then the child is punished.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements. Rationale: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On data collection of the client, the nurse expects to note which finding?

Rhythmic respirations with periods of apnea Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

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

Set limits on the child's behavior. Rationale: 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.

The nurse assigned to care for an older adult client places an extra blanket in the client's room. The nurse understands that the older adult is less able to regulate hot and cold body changes because of alterations in the activity of which gland?

Sweat glands Rationale: Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation. The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels and by the activity of the sweat glands. As aging progresses, alterations in sweat gland activity make the glands less effective in temperature regulation, so the aging person is less able to regulate hot and cold body changes. The parotid glands are responsible for the drainage of saliva, which plays an important role in digestion. The pineal gland is a major site of melatonin biosynthesis. The thymus gland plays an immunological role throughout life.

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

Testing the six cardinal positions of gaze Rationale: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. A Snellen eye chart checks visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes check cranial nerve V (trigeminal).

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?

The child is exhibiting a normal pattern. Rationale: 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.

The nurse notes that the physical assessment findings for a client with meningeal irritation indicate a positive Brudzinski sign. The nurse understands that which observation was made?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Rationale: Brudzinski's sign is tested with the client in the supine position. The examiner flexes the client's head, and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

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

Walking three to five times a week for 30 minutes Rationale: Exercise and activity are essential for health promotion and maintenance in the older adult and for achieving an optimal level of functioning. Approximately half of the physical deterioration of the older client is caused by disuse rather than by the aging process or disease. One of the best exercises for an older adult is walking, with the goal of progressing to 30-minute sessions three to five times each week. Swimming and dancing are also beneficial.

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

Wheezes Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces).