Unit 13,14,15

A 5-year-old girl is pretending to be a crocodile during a physical examination. Her mother just smiles and rolls her eyes at the nurse. What would be the best response for the nurse to give the child? "What a wonderful imagination you have! I've never seen anyone who was so good at pretending to be a crocodile." "My dear, you are a girl, not a crocodile. Now sit still so that I can examine you." "Oh no! I have a crocodile in my room. Please don't bite me!" "What happened to my client? Did you eat her?"

"What a wonderful imagination you have! I've never seen anyone who was so good at pretending to be a crocodile."

By 6 years of age, the child's skull

90% of adult size

36 months fine motor gross motor

copies a circle and draw straight line and holds cup by handle balance on one foot and jump in one place

While speaking to the caregiver of a 13-year-old girl, the nurse learns the client is struggling to accept the changes occurring to her body as a result of puberty. Which statement will the nurse include while responding to the client's caregiver? "Adolescents are often uncomfortable with their new body images and must learn to accept it." "Once puberty ends, your daughter will feel more confident in her body changes." "Be sure to tell your daughter she is beautiful often to promote a positive self-image." "These are feelings all adolescent girls experience. Have your daughter talk to her peers."

"Adolescents are often uncomfortable with their new body images and must learn to accept it."

Which instruction should the nurse give to a client to ensure that a nasal medication is deposited within the nose rather than into the throat? "Place a rolled towel beneath the neck if you are unable to sit." "Aim the tip of the container toward the nasal passage." "Breathe through your mouth as the drops are instilled." "Remain in the sitting position for 5 minutes."

"Aim the tip of the container toward the nasal passage."

A nurse cares for an older adult client who is taking over ten different medications or supplements. What statement made by the nurse best assesses the client for medication interactions? "At what pharmacy do you fill your medications?" "Have you read the prescribing information on your medications?" "What is your knowledge about medication interactions?" "Can you please tell me what each of your medications are for?"

"Can you please tell me what each of your medications are for?"

Which statement made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history? "How has the stroke affected your ability to perform your daily activities?" "What have your daily blood pressure and pulse rate readings been?" "Tell me about your family's history with heart disease." "Have you been taking your blood pressure medication exactly as prescribed?"

"How has the stroke affected your ability to perform your daily activities?"

During a routine wellness examination, the nurse is trying to determine how well a 5-year-old boy communicates and comprehends instructions. What is the best specific trigger question to determine the preschooler's linguistic and cognitive progress? "Does your son speak in complete sentences all the time?" "How well does your son communicate or follow instructions?" "Is your son's speech clear enough that anyone can understand it?" "Would you say your son has a vocabulary of about 900 words?"

"How well does your son communicate or follow instructions?"

The nurse has just completed a teaching session with clients on safety precautions to take when applying a transdermal patch. Which statement made by the client indicates that the teaching was effective? "I will change the patch every 30 days." "I will shave my chest before applying the patch." "I will dispose of the patch with adhesive sides sticking together." "I will keep the patch off twice as much as how often I keep it on."

"I will dispose of the patch with adhesive sides sticking together."

A family whose religion limits the use of some forms of technology is admitting their grandfather to the nurse's unit. They express skepticism about the fact that the nurse is recording the admission data on a laptop computer. What would be the nurse's best response to their concerns? "It's been found that using computers improves our clients' care and improves communication." "We have found that it is easier to keep track of our clients' information this way rather than with pen and paper." "You'll find that all the hospitals are doing this now, and that writing information with a pen is rare." "The government is telling us we have to do this, even though most people, like yourselves, are opposed to it."

"It's been found that using computers improves our clients' care and improves communication."

An older adult client has been prescribed a transdermal patch. Which client statement demonstrates the need for further teaching by the nurse? "I will remove the patch before I have my MRI tomorrow." "When changing patches, I will change the location of application." "This medication is likely to work slower on me than on a younger person." "I will close the adhesive edges of the patch before I dispose of it."

"This medication is likely to work slower on me than on a younger person."

Which statement made by the nurse would be a nontherapeutic response when the patient says, "I will not take pain medication when I am in pain"? "Is there another way you have learned to lessen pain when you experience it?" "Let a nurse know when you are in pain so you can be helped to decrease stimuli that may exaggerate your pain experience." "Refusing medication can only hurt you by increasing your awareness of the pain experience." "You have the right to make that decision. How can the nurses help you cope with your pain?"

"Refusing medication can only hurt you by increasing your awareness of the pain experience."

A nurse is formulating a nursing diagnosis for a patient with a respiratory disease. Which of the following would be correct? "needs nasal oxygen to improve breathing" "cough related to ineffective airway clearance" "ineffective airway clearance related to thick mucus" "refuses to cough and expectorate thick mucu

"ineffective airway clearance related to thick mucus"

Sensorimotor Phase

0 to 2 y/o -linked entirely to desires for physical satisfaction. -newborn feels, hears, sees, tastes, and smells countless new things and moves in an apparently random way.

Trust versus Mistrust

0-1 y/o to interpret cues positively needs hold, cuddle, and talk to infant; cries for communicating

The nurse is teaching a client with diabetes about insulin pen injection. The nurse will teach that the insulin in prefilled pens is stable for how long? 14 days 1 month 1 year indefinitely

1 month

Autonomy versus Doubt and Shame

1 to 3 y/o wants to feel in control and needs to learn to perform tasks independently, even when this takes a long time or makes a mess. The toddler gains reassurance from self-feeding, from crawling or walking alone where it is safe, and from being free to handle materials and learn about things in the environment

A nurse is teaching a client the use of a metered-dose inhaler. For how many seconds should the client hold the breath to allow the medication to reach the lungs? Record your answer using a whole number.

10

Typical development for the school-aged child includes playing games with friends. At what age are children typically ready for games that include playing on a team that has a winner or loser? 5 years 7 years 10 years 13 years

10 y/o

A client is prescribed a transdermal nitroglycerin patch. The nurse will teach the client to wear the patch for: 3 to 6 hours. 6 to 8 hours. 10 to 12 hours. 12 to 14 hours.

12 to 14 hours.

formal operations

12 to 15 y/o -abstract concepts described only in words or symbols -can observe and then draw logical conclusions from their observations.

Identity versus Role Confusion

12 to 18 y/o The adolescent develops a sense of being an independent person with unique ideals and goals and may feel that parents, caregivers, and other adults refuse to grant that independence. Adolescents may break rules just to prove that they can. Stress, anxiety, and mood swings are typical of this phase. Relationships with peers are more important than ever.

Preoperational Phase

2 to 7 y/o -egocentric, that is, he or she cannot look at something from another's point of view. -A sense of time is not yet developed; thus, the preschooler or early school-aged child cannot always tell if something happened a day ago, a week ago, or a year ago.

x Which gauge needle is the nurse expected to use to administer dimenhydrinate 50 mg? 27-gauge 26-gauge 25-gauge 22-gauge

22

Initiative versus Guilt

3 to 6 y/o active, assertive play. Steadily improving physical coordination and expanding social skills encourage "showing off" to gain adult attention and, the child hopes, approval. The preschool child, still self-centered, plays alone, although in the company of other children; interaction comes later

The nurse is to administer 250 mg of a drug to a client. The label on the bottle reads 500 mg/5 ml. Which instrument is best for the nurse to use? plastic medication cup 3-mL syringe bottle cap household teaspoon

3-mL syringe

An individual is considered obese when their BMI is what value? <18.5 18.6-24 25-29.9 30-39

30-39

Industry versus Inferiority

6 to 12 y/o Praise, not criticism, helps the child build self-esteem and avoid feelings of inferiority. It is important to emphasize that everyone is a unique person and deserves to be appreciated for his or her own special qualities.

Concrete operations

7 to 11 y/o -children develop the ability to begin problem solving in systematic way -classify and organize information about their environments -children begin to understand that volume or weight may remain the same even though the appearance changes

A hospitalized 7-year-old is recovering from a head injury. Occupational therapy has been ordered to assist the child in regaining eye/hand coordination. If the child cannot master this skill, what feelings may arise? A sense of mistrust A sense of doubt A feeling of inferiority A sense of shame

A feeling of inferiority

The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take? Count after the child stops crying and is comfortable. Count the respiratory rate for 30 seconds. Count abdominal movements. Place a stethoscope to count respirations.

Count after the child stops crying and is comfortable.

The following nursing diagnoses are formulated with a client: constipation, acute pain, and caregiver role strain. During the planning phase of the nursing process, the nurse will prioritize the diagnoses in what order? Acute pain, constipation, caregiver role strain Constipation, acute pain, caregiver role strain Caregiver role strain, acute pain, constipation Caregiver role strain, constipation, acute pain

Acute pain, constipation, caregiver role strain

The health care provider has given and signed an order for a specific client for zolpidem, 10 mg by mouth once daily at hour of sleep, and recorded the specific date and time of the order. What is the appropriate nursing action? Administer the drug. Cosign the order. Call the health care provider for order clarification. Show the order to the nurse manager.

Administer the drug.

Based on Maslow's Hierarchy of Needs, when prioritizing a patient's plan of care, what would be the nurse's first priority? Allowing the family to see a newly admitted patient Ambulating the patient in the hallway Administering pain medication Teaching the patient to self-administer insulin

Administering pain medication

A parent tells the nurse that the 6-year-old child has been biting his fingernails since beginning first grade. After analysis, the cause is determined to be increased stress. What advice would the nurse give the parent regarding this behavior? Encourage the child to drink more milk for stronger nails. Distract the child by teaching a new skill, such as whistling. Allow some time every day for the child to talk about new experiences Allow the child to choose a reward for not biting the nails.

Allow some time every day for the child to talk about new experiences

A nurse is examining a 17-year-old adolescent in the emergency room who is being disruptive in the waiting area. On assessment, the nurse finds dilated pupils, and the teen is talking very fast. Which of the following drugs does the nurse suspect the teen may be abusing? Opiates Marijuana Amphetamines Barbiturates

Amphetamines treat for ADD

The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply. Around 5 months the infant may develop "stranger anxiety." Around 2 months the infant exhibits a first real smile. Around 3 months the infant smiles widely and gurgles when interacting with the caregiver. Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue. Around 3 to 6 months of age the infant may enjoy socially interactive games such as patty-cake and peek-a-boo. Separation anxiety may also start in the last few months of infancy.

Around 2 months the infant exhibits a first real smile. Around 3 months the infant smiles widely and gurgles when interacting with the caregiver. Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue. Separation anxiety may also start in the last few months of infancy.

When obtaining a health history from an older adult patient, what should the nurse remember to do? (Select all that apply.) Ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired. Clarify the frequency, severity, and history of signs and symptoms of the present illness. Conduct the interview in a calm, unrushed manner using eye-to-eye contact. Have a family member in the room when asking questions to make sure the patient's answers are accurate. Frequently touch the patient so that you may bring his or her attention back to the interview.

Ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired. Clarify the frequency, severity, and history of signs and symptoms of the present illness. Conduct the interview in a calm, unrushed manner using eye-to-eye contact.

A 2-year-old wants to feed herself and becomes agitated when the nurse attempts to feed her. What does the nurse understand is the developmental age of this child according to Erikson? Trust vs. mistrust Autonomy vs. doubt and shame Initiative vs. guilt Industry vs. inferiority

Autonomy vs. doubt and shame

A client is scheduled to receive a sustained-release capsule of an antidepressant medication each morning at 0800. Recent changes in the client's level of consciousness have resulted in some difficulty swallowing and occasional coughing while eating and drinking. The nurse has been instructed by a colleague to crush the client's pills and administer them mixed with applesauce in an effort to make the medications easier to swallow. How should the nurse respond to this colleague's advice? Split the capsule into two smaller halves but avoid crushing it. Avoid opening the capsule in order to preserve the sustained release of the drug. Mix the contents of the capsule with the applesauce . Administer a similar drug that is easier for the client to swallow.

Avoid opening the capsule in order to preserve the sustained release of the drug.

A nurse's assessment of a new client includes each of the four basic assessment techniques. When using percussion, which of the following is the nurse able to assess? Borders of the client's heart Movement of the client's diaphragm during expiration Turbulent flow in the heart The presence of rectal distension

Borders of the client's heart

A nurse receives orders from the physician to mix a client's insulin in a syringe with two other medications. What is the recommended guideline in this situation? It cannot be done because it is not possible to mix more than two medications in one syringe. Call the physician to determine the necessity of mixing the three drugs or to see if they are compatible. Call the pharmacist to determine compatibility of the drugs. Check with the nursing team before mixing and administering the drugs.

Call the pharmacist to determine compatibility of the drugs.

A nurse is applying a vaginal cream to a client with a fungal infection. Which guideline is recommended for this application? Position the client in a left side-lying position. Cleanse area at vaginal orifice with washcloth and warm water. Wipe from the sacrum to the vaginal orifice upward (back to front). Spread the labia with dominant hand and introduce the applicator gently with the nondominant hand.

Cleanse area at vaginal orifice with washcloth and warm water.

The nurse is teaching the parents of a 9-year-old girl about the socialization that is occurring in their child through school contacts. Which information would the nurse include in her teaching plan? Teachers are the most influential people in the development of the school-age child's social network. Continuous peer relationships provide the most important social interaction for school-age children. Parents should establish norms and standards that signify acceptance or rejection. A characteristic of school-age children is their formation of groups with no rules and values involved.

Continuous peer relationships provide the most important social interaction for school-age children.

When performing a physical examination on a child, the nurse notes a mirror image in the shape and position of the child's chest and abdomen. Which nursing action is appropriate? Document the finding in the medical record. Notify the primary health care provider. Measure each with a tape measure. Assess the child's bowel sounds.

Document the finding in the medical record.

A client is prescribed an HMO-CoA reductase inhibitor for the treatment of elevated cholesterol and triglyceride levels. Which education will the nurse provide to the client regarding the medication prescribed? Liver function and glucose levels will be checked periodically. Muscle pain and weakness is a common side effect of the medication. The medication will lower the high-density lipoproteins. Eliminate fats in the diet and substitute with carbohydrates.

Liver function and glucose levels will be checked periodically.

What statement does the nurse determine is a medical diagnosis rather than a nursing diagnosis? Fever of unknown origin Fluid volume excess Risk for falls Sleep-pattern disturbances

Fever of unknown origin

A nurse instills ear drops into a client's ear to soften a wax buildup. Which guideline should the nurse follow? Pull the pinna down and back for a child over 3 years of age and straight back for an infant or a child younger than 3 years. Avoid ear drops if the ear canal has swollen to the point that medication cannot pass. Hold the dropper with its tip resting on the ear. If both ears are to be treated, wait 5 minutes before instilling drops in the second ear.

If both ears are to be treated, wait 5 minutes before instilling drops in the second ear.

The nurse is assessing a client's abdomen and percusses a large area of dullness on the right side of the abdomen, not the expected tympany. What has the nurse percussed? Lungs Empty stomach Liver Full bladder

Liver

Which instruction by the nurse could assist the client in estimating the amount of medication in the canister? Shake the canister. Press down on the canister once. Insert the canister into the holder. Look on the canister and see how many puffs the canister contains

Look on the canister and see how many puffs the canister contains

A mother describes her 4-year-old girl's eating habits as "picky" and goes on to describe using coaxing and threatening measures to get her to eat. The girl is at the 40th percentile for weight and 50th percentile for height. What interventions will be suggested? Select all that apply. Offer a variety of healthy foods including those liked and refused. Approach mealtime matter-of-factly. Allow the child to decide how much she will eat. Ignore the pickiness and require her to clean her plate. Offer only nutritious between-meal snacks. Focus on quality, not quantity.

Offer a variety of healthy foods including those liked and refused. Approach mealtime matter-of-factly. Allow the child to decide how much she will eat. Offer only nutritious between-meal snacks. Focus on quality, not quantity.

The nurse is caring for a 3-year-old at a well-child checkup. The parent states that her child still has an afternoon nap but she has a friend whose toddler no longer naps in the afternoon. She is seeking advice on what do to. When providing anticipatory guidance to the parent about sleep patterns, what is the most appropriate response by the nurse? "Children no longer nap in the afternoon after 1 year." "Children begin to give up afternoon napping at 2 years." "Often, the afternoon nap will be no longer needed after 4 years." Since they are in school now all day, napping ends at 6 years.

Often, the afternoon nap will be no longer needed after 4 years."

A nurse is caring for a hospitalized 10-year-old child. What would be an appropriate activity for this child to meet the developmental tasks of this age group? Participating in a craft project Playing with a jack-in-the-box Playing with blocks Writing letters to friends

Participating in a craft project

The admitting nurse has just met a new client who has been admitted from the emergency department. As the nurse introduces himself, he begins the process of inspection. What nursing action should the nurse include during this phase of assessment? Gather as many psychosocial details as possible. Pay attention to the details while observing. Write down as many details as possible during the observation. Do not let the client know he is being assessed.

Pay attention to the details while observing.

A mother is concerned about her 2-year-old son acquiring sufficient protein while following the family's vegan diet. Which of the following foods would be appropriate for the nurse to recommend to this mother? Peanut butter and wheat bread Milk and cheese Eggs Broccoli

Peanut butter and wheat bread

The nurse notes hyperresonance over inflated lung tissue when performing a physical assessment on a patient with emphysema. What process does the nurse use for this assessment? Auscultation Inspection Palpation Percussion

Percussion

When administering oral medications, which practices should the nurse follow? Select all that apply. Dispense multiple liquid medications into a single cup to reduce the number of containers the client must handle. Perform hand hygiene before and after medication administration. Stay at the bedside until the client has swallowed all the medications. Store the client's MAR at the bedside at all times to ensure safe identification. Verify the client's response to the medication 30 minutes after administration or as appropriate for the drug.

Perform hand hygiene before and after medication administration. Stay at the bedside until the client has swallowed all the medications. Verify the client's response to the medication 30 minutes after administration or as appropriate for the drug

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action? Discard the remaining drug. Place the date on the vial and retain for future use. Draw up the remaining medication to give at the next time of administration. Send the vial with the remaining drug back to the pharmacy.

Place the date on the vial and retain for future use.

The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone? No extra documentation is necessary. Have another nurse cosign the order input. Tell the provider to sign the order as soon as possible. Record "T.O." at the end of the order.

Record "T.O." at the end of the order.

A client with history of COPD, is admitted to the unit. As the LPN/LVN completes the first portion of the database interview, the nurse chooses to auscultate lung sounds as the client's respiratory distress increased during the interview. After auscultation, what is the LPN/LVN's next step? Report the client's increased respiratory distress to the RN for immediate assessment. Continue the assessment until complete. Complete the paperwork, then continue the assessment. Call the physician with the client's increased respiratory rate after completing the assessment.

Report the client's increased respiratory distress to the RN for immediate assessment.

Which of the following can have an influence over the individual's physiologic growth and development trajectory? Sensory stimulation and nutrition Ethnicity and culture Temperament Intelligence

Sensory stimulation and nutrition

An infant who is 4 months old continues to be seen at doctor visits for illness prevention. What would be the next scheduled appointment that this infant should attend to be evaluated? The next visit would be in 1 month. The next visit would be at 6 months. The next visit would be in 3 months. The next visit would be at 9 months.

The next visit would be at 6 months.

A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection? Sites commonly used for a subcutaneous injection are the inner surface of the forearm and the upper back, under the scapula. Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. Subcutaneous injections are administered at a 30- to 45-degree angle based on the amount of subcutaneous tissue present. Pinching is advised for obese clients to lift the adipose tissue away from underlying muscle and tissue.

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis.

When prioritizing a patient's plan of care according to Maslow's Hierarchy of Needs, what would the nurse focus on last? Allowing family members to see a newly admitted patient Ambulating the patient in the hallway Administering pain medication to the patient Teaching the patient to self-administer insulin

Teaching the patient to self-administer insulin

Which statements made by the nurse indicate how insulin pens simplify self-administered insulin for clients? Select all that apply. "The plastic cylinders of insulin pens are softer." "Insulin pens are less expensive than insulin vials." "The cylinder of the insulin pen contains a prefilled reservoir of insulin." "The dose of insulin in an insulin pen is displayed in a window of the syringe." "The insulin pen automatically resets the dose window to zero, following the injection."

The cylinder of the insulin pen contains a prefilled reservoir of insulin." "The dose of insulin in an insulin pen is displayed in a window of the syringe." "The insulin pen automatically resets the dose window to zero, following the injection."

when teeth begin to grow

The first deciduous teeth, usually the lower central incisors, usually erupt between 6 and 8 months of age

The emergency department (ED) nurse demonstrates the proper abdominal assessment technique in which scenario? Using the fingertips, the nurse palpates the four abdominal quadrants, protects client privacy while visually inspecting the abdomen, warms the stethoscope before listening for bowel sounds, and lightly percusses the abdomen. Using the surface of the palm, the nurse palpates the skin temperature of the abdomen, warms the stethoscope before listening for bowel sounds, protects client privacy while visually inspecting the abdomen, and lightly percusses the abdomen. The nurse protects client privacy while visually inspecting the abdomen, warms the stethoscope before listening for bowel sounds, uses the fingertips to lightly palpate the four abdominal quadrants, and taps the four abdominal quadrants. The nurse lightly taps the four abdominal quadrants, uses the fingertips to palpate the four abdominal quadrants, warms the stethoscope before listening for bowel sounds, and protects patient privacy while visually inspecting the abdomen.

The nurse protects client privacy while visually inspecting the abdomen, warms the stethoscope before listening for bowel sounds, uses the fingertips to lightly palpate the four abdominal quadrants, and taps the four abdominal quadrants

Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler? The nurse should instruct the child to prolong his/her inhalation. The nurse should use a nebulizer to administer the medication. The nurse should assess the child's mucous membranes. The nurse should provide simple written instructions.

The nurse should use a nebulizer to administer the medication.

A nurse is percussing a patient's abdomen. The nurse understands that which sound indicates tissue with the LEAST density? Tympany Hyperresonance Dullness Flatness

Tympany

A nurse is preparing to administer an intramuscular injection to a client. Which would be appropriate for the nurse to do to reduce discomfort? Select all that apply. Use a large-gauge needle. Use the Z-track technique. Have the client lie prone with toes outward. Apply ice to the site before administration. Apply pressure to the site when withdrawing the needle.

Use the Z-track technique. Apply ice to the site before administration. Apply pressure to the site when withdrawing the needle.

During review of a plan of care for a client, the nurse determines that the outcomes have not been achieved. The nurse believes an error may have been made during the planning phase of the nursing process. Based on this belief, which of the following should the nurse consider during this evaluation step? Was the appropriate nursing diagnosis chosen? Do the nursing interventions need revision? Have new problems evolved requiring different interventions? Were the time frames appropriate to achieve the expected outcomes?

Were the time frames appropriate to achieve the expected outcomes?

The nurse knows that a drug paste differs from a drug ointment in that: a paste is not massaged into the skin. a paste has a thinner base. nitroglycerin is available only in ointment form. pastes do not need to have their sites of administration rotated.

a paste is not massaged into the skin.

A community health nurse who provides care for numerous older adults is aware of the problem of polypharmacy among this population. Which individual is at greatest risk for polypharmacy? a woman who uses two different pharmacies in the community to purchase her medications a man who prefers to take liquid medications rather than pills, capsules, or tablets a woman whose prescribed medication regimen includes many different drugs a man who has medications prescribed for several times throughout the day

a woman whose prescribed medication regimen includes many different drugs

3 y/o fine gross motor

able button clothes, show preference right or left hand can jump several feet, rides tricycle

dramatic associative cooperative play

allows a child to act out troubling situations and to control the solution to the problem children play in an organized group with each other, as in team sports occurs when children play together and are engaged in a similar activity but without organization, rules, or a leader, and each child does what he or she wishes

A nurse is preparing to apply a liquid inunction to a client's lower leg. Which action would be least appropriate? applying the drug with the fingertips applying ice to the site after administration rubbing the medication into the skin shaking the bottle of medication before applying

applying ice to the site after administration

A client just returned to the unit following abdominal surgery and is in significant pain. Understanding the nursing process, the nurse is aware that assessment will be performed on the client how many times? as often as needed once upon arrival, and one hour later once upon arrival twice per shift

as often as needed

18 months fine motor gross motor

better control spoon and better with cup; turn pages walks alone and side ways and backwards

12-15 months fine motor gross motor

build with blocks; able to reach out and hold food and spoon and drinks from cup able to stand take few steps independent

4 y/o fine gross motor

can use scissors hop on one foot and move hands

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection? checking for documented allergies to food or drugs preparing the syringe with the medication cleaning the area with an alcohol swab gathering all the equipment needed

checking for documented allergies to food or drugs

Which of the following group of terms best defines assessing in the nursing process? problem focused, time lapsed, emergency based design a plan of care, implement nursing interventions collection, validation, communication of patient data nurse focused, establishing nursing goals

collection, validation, communication of patient data

z track The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe? decreased irritation and pain in subcutaneous tissue less frequent administration of the medication more rapid administration of the medication decreased risk for infection

decreased irritation and pain in subcutaneous tissue

The nurse is developing a client's care plan. What activity bestexemplifies the assessment phase of the nursing process? assist with ambulation give a complete bed bath determines the client has a pulse rate of 88 bpm check blood pressure daily

determines the client has a pulse rate of 88 bpm

24 months fine motor gross motor

draw enclose shapes, flips pages, and build tower of blocks walk up and down stair one step at time, run, throws and kicks ball

A client has been prescribed nitroglycerin. The nurse would carefully check the client's chart to ensure that there is no use of: drugs for erectile dysfunction. drugs for motion sickness. calcium supplements. drugs for smoking cessation.

drugs for erectile dysfunction.

The nurse is preparing to measure the head circumference of a 6-month-old infant. How should the nurse make this measurement? from the hairline in front to the hairline in back from the center of the forehead to the posterior fontanelle from above the eyebrows through the prominent part of the occiput from the middle of the forehead through the parietal prominences

from above the eyebrows through the prominent part of the occiput

The client is prescribed two metered-dose inhalers (MDI). One medication is a bronchodilator, and the other medication is a corticosteroid. When administering the medications, the nurse: has the client use the bronchodilator MDI first. administers the MDIs within 1 minute of each other. instructs the client to rinse the mouth before using the second inhaler. teaches the client to hold the breath for 5 seconds after each inhalation.

has the client use the bronchodilator MDI first.

infant BP resp rate

he average blood pressure during the first year of life is 85/60 mm Hg. 30 to 45

A client was admitted to the medical unit with a history of having difficulty breathing despite being compliant with the prescribed inhalers. On assessment, the client's respiration is 36 breaths/min and oxygen saturation is 96%. Which nursing diagnosis is the nurse expected to record? impaired tissue perfusion impaired gaseous exchange ineffective breathing pattern ineffective airway clearance

ineffective breathing pattern

What is the most inclusive definition of critical thinking? intentional, contemplative, and outcome-directed thinking the process of evaluating potential outcomes careful analysis of a problem that considers all aspects a deliberate approach to problem solving

intentional, contemplative, and outcome-directed thinking

Nursing students are reviewing information about the absorption of medications administered parenterally. The students demonstrate understanding of the information when they identify the methods listed from fastest to slowest onset. Place these methods in the order that demonstrates the students' correct understanding.

intravenous intramuscular subcutaneous intradermal

Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures? Small bowel Bladder Liver Abdominal skin

liver

Preschoolers have learned to think about something without actually seeing it—to visualize or imagine. This normal development, sometimes

magical thinking

what type of play during toddler stage

parallel play

A nurse uses a nitroglycerin paste to dilate the coronary arteries of a client at the health care facility. What should the nurse do to facilitate the medication absorption? rotate the site of medication placement avoid touching the application with bare fingers apply the new application before removing the existing application place application paper on a non-hairy area of skin

place application paper on a non-hairy area of skin

A nurse is speaking with a 7-year-old boy in the hospital. The boy asks the nurse, "Where is the westroom? I need to use the westroom." The nurse recognizes that this developmental problem is which of the following? Poor articulation Broken fluency Malocclusion Caries

poor articulation

An LPN/LVN who works on a very busy orthopedic unit participates in the admission process whenever a new client arrives. The LPN/LVN's level of involvement in the physical assessment is determined by education, experience, and: scope of practice. personal preference. delegation of tasks by the RN. physician direction.

scope of practice.

An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method? a container with enough prescribed medications for several days for a client self-contained packets that hold one tablet or capsule for individual clients a supply that remains on the nursing unit for use in an emergency systems that contain frequently used medication for that unit

self-contained packets that hold one tablet or capsule for individual clients

The client has diabetes and is taking Novolin 70/30. The client is being seen for several episodes of hypoglycemia. A nursing diagnosis of Risk for Ineffective Self-Health Management is made. The nurse intervenes by teaching the client about which topics? Select all that apply. signs and symptoms of low blood glucose level to check blood glucose level daily 2 hours after a meal about onset, peak, and duration of insulin to eat within 1 hour of administering the insulin foods and beverages that will raise the blood glucose level

signs and symptoms of low blood glucose level about onset, peak, and duration of insulin foods and beverages that will raise the blood glucose level

The nurse is preparing to administer nasal medication via a dropper to a client with severe congestion. Into which position will the nurse place the client? prone supine oblique lithotomy

supine

during the school-aged years, the child's cognitive skills develop with conservation

the ability to recognize that a change in shape does not necessarily mean a change in amount or mass

A postsurgical client has been experiencing pain, and the nurse has administered a subcutaneous injection of the opioid hydromorphone. The nurse should know that this injection deposited the medication into what location in the client's tissue? the region between the epidermis and the dermis the vasculature in the client's skeletal muscles the area beneath the skin but above the muscles the tissue between the client's muscles and bones

the area beneath the skin but above the muscles

A longterm care facility's newest client refuses to attend group activities or social events offered by the facility. Which level of Maslow's hierarchy do social events address? third: love and belonging needs second: safety and security needs fifth: self-actualization needs fourth: esteem and self-esteem needs

third: love and belonging needs

5 y/o fine gross motor

ties shoelace, print few letter, may print name throw and catch ball well, jumps rope, walks backward, skip and hop

A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? to implement evidence-based practice to ensure the order follows hospital policy to be sure interventions are individualized to be sure the intervention is safe

to be sure the intervention is safe

The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? to gather data about a specific and current health problem to identify life-threatening problems that require immediate attention to compare and contrast current health status to baseline data to establish a database to identify problems and strengths

to establish a database to identify problems and strengths

The nurse assesses a 6-month-old. What body part should show significant growth? The head The trunk The legs The abdomen

trunk

The nurse is caring for a confused client who requires a transdermal patch application. Which location will the nurse choose to apply the patch? side of buttock upper arm lower abdomen upper back

upper back

A client presents to the acute care facility with several signs and symptoms. How will the nurse determine and prioritize the client's healthcare needs? using a systematic method to plan and implement care to reach desired outcomes contacting the physician before performing any tasks consulting with other nurses to determine the first step of care reading the client's records and doing research on the client's conditions before deciding on a course of action

using a systematic method to plan and implement care to reach desired outcomes

Dawdling Temper tantrums

wasting time or being idle, serves the purpose of asserting independence aggressive displays of temper during which the child reacts with rebellion to the wishes of the family caregiver, spring from the many frustrations that are natural results of a child's urge to be independent

The child has learned to crawl and walk, and later throws a ball and knows the names of colors. Which principle of growth and development is the child demonstrating? Hereditary determinants Predictable patterns and maturation Cephalocaudal and proximodistal progress Directional growth and adaptability

Cephalocaudal and proximodistal progress

Which measures should receive priority in the care plan for an infant client who has sensitive skin? Use scented wipes with stool Use baby power with each change Change diapers frequently Use only cloth diapers

Change diapers frequently

When teaching parents, what information should the nurse include related to healthy diets for children? Select all that apply. Eat a high grain diet, with vegetables and fruits. Children should experience a variety of foods. Eat sugars in moderation for obesity control. Exercise is more important than dietary intake. Heavy salt is needed for thyroid health.

Children should experience a variety of foods. Eat sugars in moderation for obesity control.

The school nurse is developing a school wellness program to promote healthy eating habits and regular physical activity. What is the most important element to emphasize to maximize compliance, healthy habits, and long-term change? Eliminate sweetened, carbonated beverages in the cafeteria. Serve fruits and vegetables in the cafeteria. Incorporate activity in parts of the daily schedule. Include both parents and children in the wellness program.

Include both parents and children in the wellness program.

Which would be a nutritional goal for a preschool client? Eat everything on the plate. Introduce new food gradually and include variety. Reduce messiness and spills. Let the child eat only what the child wants.

Introduce new food gradually and include variety.

The nursing student is reviewing growth and development of children. The student is interested in how children develop the knowledge of what is right and what is wrong in their younger years of development. Which theorist would the nursing student want to review? Erikson Freud Piaget Kohlberg

Kohlberg

The parents of a 2-year-old child born with short-gut syndrome feed their toddler via a feeding tube. Knowing this is a developmental time when children usually feed themselves, the parents are asking the nurses what they can do to help foster the child's independence. Which suggestion would be most appropriate at this time? Play catch with the child while others are eating so they do not have to feel left out. Let the child choose what clothing he or she will wear the next day. Try to focus the child's energy on learning to read simple books that are age appropriate. Imitate placing food in the child's mouth as long as the food is large enough so it cannot be swallowed.

Let the child choose what clothing he or she will wear the next day.

The school nurse is performing health assessments on students in middle school. Of what developmental milestone should the nurse be aware? Height in girls increases rapidly after menarche and usually ceases increasing immediately after menarche. Boys' growth spurts usually begin between the ages of 8 and 14 years and end between the ages of 13½ and 17½ years. Peak height velocity (PHV) occurs at approximately 12 years of age in girls or about 6 to 12 months after menarche. Boys reach PHV and peak weight velocity (PWV) at about 16 years of age.

Peak height velocity (PHV) occurs at approximately 12 years of age in girls or about 6 to 12 months after menarche.

The nurse is counseling parents of a picky eater on how to promote healthy eating habits in their child. Which intervention would be appropriate advice? Allow the child to pick out his or her own foods for meals. Present the food matter-of-factly and allow the child to choose what to eat. Offer high-fat snacks if the child does not eat to get him or her to eat something. Offer the child a special treat if he or she eats all the food on the plate.

Present the food matter-of-factly and allow the child to choose what to eat.

The nurse is helping the parents and their underweight adolescent collaborate on planning a healthy menu. The nurse should be aware of which nutritional requirement of adolescents? Teenagers have a need for increased calories, zinc, calcium, and iron for growth. Teenage girls who are active require about 1,800 calories per day. Teenage boys who are active require between 2,000 and 2,500 calories per day. Adolescents require about 1,000 to 1,200 mg of calcium each day.

Teenagers have a need for increased calories, zinc, calcium, and iron for growth.

The nurse pours liquid medication from one tall container to a shorter container. How would the preschool-age child interpret this exchange of the medication? The amount of medicine is less. The glass changed shape to accommodate the medicine. Pouring medicine hurts it in some way because it changes. The amount of medicine did not change, only the appearance.

The amount of medicine is less.

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

The child can hop on one foot.

A nurse is caring for a child in the emergency department who has had a cast applied for a fractured arm. The nurse is providing information to the parent on cast care and asks the parent if there are further questions about the cast. The parent stares at the nurse and shrugs. What might this indicate to the nurse? The parent may have a further concern and does not know how to express it. The parent does not care about the cast care. The parent probably already knows how to care for the cast and just wants to go home. The parent does not want to take the child home.

The parent may have a further concern and does not know how to express it.

The school nurse is teaching a class on sports injuries. What information is most important for the nurse to teach? Play the same sport regularly to become proficient. Vary the sports to prevent use injuries. Little league tackle football is not safe for a school age child. Fractures are minimal due to bone growth and calcification.

Vary the sports to prevent use injuries.

The nurse is providing health-promotion teaching to a group of parents of preschoolers at a local day care. What information would the nurse include in this education session? Select all that apply. Preschoolers are capable of taking a bath independently. Encourage children to select their own clothing to wear each day. Parents will need to supervise tooth-brushing and be responsible for flossing. Treat any toileting accidents in a matter-of-fact manner and assist the child in getting dry clothing. Preschoolers only need to wear bicycle helmets if they are going on long rides.

Encourage children to select their own clothing to wear each day. Parents will need to supervise tooth-brushing and be responsible for flossing. Treat any toileting accidents in a matter-of-fact manner and assist the child in getting dry clothing.

During a health check-up without the parents present, a 17-year-old adolescent tells the nurse about being gay. Which statement from the nurse is best? "Tell me what makes you think you are gay." "This puts you in an at-risk category." "We need to talk about safe sex." "You are not gay; you are confused."

"Tell me what makes you think you are gay."

At which age would the nurse expect to find the beginning of object permanence? 1 month 6 months 9 months 12 months

6 months

The student nurse is preparing a presentation on signs of developmental delay in preschoolers. Which examples of delays should be included? Select all that apply. A 5-year-old that cannot use plurals or past tense when speaking. A 4-year-old who grasps a crayon with thumb and fingers. A 5-year-old who wants to play with friends. A 4-year-old that does not use sentences with three or more words. A 4-year-old that does not engage in fantasy play.

A 5-year-old that cannot use plurals or past tense when speaking. A 4-year-old that does not use sentences with three or more words. A 4-year-old that does not engage in fantasy play.

A nurse is working with a family that has two children who were identified as overweight based on screening. Which of the following strategies would be important for the nurse to include in assisting the family? Select all that apply. Encouraging moderate exercise for 60 minutes/day Emphasizing that the family not skip meals Involving the entire family in the program Focusing on rapid weight loss regimens Using food as a punishment

Encouraging moderate exercise for 60 minutes/day Emphasizing that the family not skip meals Involving the entire family in the program

The nurse is assessing a 6-month-old infant in the clinic. Which characteristic represents normal language development for this age? Cooing Laughing out loud Babbling Producing noises when spoken to

Babbling 5 months cooing

All humans learn from both formal and informal experiences. What orderly pattern of changes results in part from learning? Development Growth Maturity Aging

Development

Estimating illness in an infant is difficult. To help an infant's parents do this, which of the following would you instruct them to use? Take her temperature about once a week. Call if she spits up any formula. Use her interest in eating as a good gauge. Call if the infant's stools are yellow.

Use her interest in eating as a good gauge.

The parents of a 4-year-old who is a picky eater ask the nurse what foods to include in their child's diet to provide adequate iron consumption. Which food would the nurse recommend? cooked lentils whole milk oranges sweet potatoes

cooked lentils

A mother suspects that her 11-year-old son is experimenting with deliriants with his friends. Which symptoms would the nurse advise the mother to look for that would validate her concerns? Having bad breath when returning from school Giddiness and coughing Unexpected bouts of diarrhea Hyperactivity

Giddiness and coughing

A nurse is educating a middle school class of male adolescents about sex education. The topic of multiple partners is discussed. Which of the following statements from the nurse would be the most effective? "Teens account for 25% of all sexually transmitted infections (STI) in the population." "Be careful, or you will end up being a teen parent." "Contraception is a responsibility of both parties involved." "Compared with male teens, female teens are more susceptible to STIs."

"Contraception is a responsibility of both parties involved."

A nurse is providing health promotion education to a family of an infant at the family birth center. The nurse knows the parents need more education when they state which response? "I will switch to whole milk when my infant is around 6 months of age." "I will introduce soft foods for my infant around 6 months of age." "I will give my infant a drinking cup gradually around 6 months." "I will introduce new foods one at a time."

"I will switch to whole milk when my infant is around 6 months of age."

Parents are asking a pediatric nurse how to deal with separation anxiety every time they try to have an adult night out. Which advice by the nurse sounds like the most appropriate way to handle this situation? "Inform the child that you are going out but the regular babysitter will care for them and put them to bed." "Try to sneak out the back door to avoid the long crying scene at the door." "If your child starts crying, stay a little longer and read a story before leaving." "Note if your child cries as you leave because this may be an indication the babysitter is ignoring the child."

"Inform the child that you are going out but the regular babysitter will care for them and put them to bed."

The nurse is teaching good sleep habits for toddlers to the parent of a 3-year-old client. Which response indicates the parent understands sleep requirements for the client? "I'll put my child to bed at 7 p.m., except Friday and Saturday." "My child needs 12 hours of sleep per day including a nap." "I should give my child a glass of milk before bed." "The routine at bedtime can fluctuate from day to day."

"My child needs 12 hours of sleep per day including a nap."

The nurse is teaching a group of caregivers of school-age children about the importance of setting a consistent bedtime for the school-age child. Which statement made by a caregiver indicates an understanding of the sleep patterns and needs of the school-age child? "My child sleeps between 11 and 12 hours a night." "My child stays up late when she takes a nap after school." "My child does not even know when he is tired." "My teenage child does not sleep as much as my 9-year-old does."

"My child sleeps between 11 and 12 hours a night."

A parent tells the nurse that a 9-year-old has to go home alone for 2 hours until the parents get off work, and they are afraid the child will begin smoking and drinking. What can the nurse inform them about "latchkey" children? "No evidence supports that children will have these behaviors if they are recognized for their dependability." "It is too dangerous in this day and time for your child to be home alone at any time." "Can't you hire a babysitter to meet the child at the house after getting off the bus?" "I left my child at home from the age of 8 years old and nothing ever happened."

"No evidence supports that children will have these behaviors if they are recognized for their dependability."

The nurse is educating foster parents regarding their recently fostered 9-year-old girl. What statement by the parents indicate the need for further assessment with regard to her age-appropriate growth and development? Select all that apply. "She has been reluctant to go to school each morning." "She was very quiet when she was put into a new classroom at school." "She seems intent on being part of a club that has a secret password." "She gets argumentative and refuses to follow the rules to board games and card games." "She is very concerned with cleanliness and showers two to three times a day most days."

"She gets argumentative and refuses to follow the rules to board games and card games." "She is very concerned with cleanliness and showers two to three times a day most days."

The nurse is providing anticipatory guidance to a mother of a 5-month-old boy about introducing solid foods. Which statement by the mother indicates that effective teaching has occurred? "I'll start with baby oatmeal cereal mixed with low-fat milk." "The cereal should be a fairly thin consistency at first." "I can puree the meat that we are eating to give to my baby." "Once he gets used to the cereal, then we'll try giving him a cup."

"The cereal should be a fairly thin consistency at first."

A 3 1/2 year-old child is found masturbating in the family living room. Which response by the parent would best address this behavior? "You need to quit that right now. It's not nice to touch your privates." "I will ask your father to talk to you about this since he is a male too." "We do not touch ourselves in public. Please go to your room if you want to continue this behavior." "Your penis is very interesting, isn't it? But you can injure it by touching it so much."

"We do not touch ourselves in public. Please go to your room if you want to continue this behavior."

During a health history, the nurse explores the sleeping habits of a 3-year-old boy by interviewing his parents. Which statement from the parents reflects a recommended guideline for promoting healthy sleep in this age group? "Our son sleeps through the night, and we insist that he takes two naps a day." "We keep a strict bedtime ritual for our son, which includes a bath and bedtime story." "Our son still sleeps in a crib because we feel it is the safest place for him at night." "Our son occasionally experiences night walking so we allow him to stay up later when this happens."

"We keep a strict bedtime ritual for our son, which includes a bath and bedtime story."

The nurse is teaching the parents of a 2-year-old child how to handle the child's temper tantrums. The nurse determines that the teaching was successful if the parents make which statement? "We will offer our child a treat to stop having the tantrum." "We will place our child in time-out for 5 minutes after the tantrum." "We will attempt to reason with our child to limit tantrums." "We will ignore our child while having the tantrum."

"We will ignore our child while having the tantrum."

The terms "growth" and "development" often are used interchangeably. To which of the following does "development" refer? A boy grows taller all through early childhood. He learns to throw a ball overhand. He triples his weight during the first year. His brain increases in size until school age.

He learns to throw a ball overhand.

A nurse is teaching parents of a 2-year-old child about discipline and limit setting. When describing the use of time out, the nurse would inform the parents that the maximum duration of time out should be how many minutes per each year of age? 1 minute 30 seconds 90 seconds 2 minutes

1 minute

A pediatric nurse is providing care to several children. The nurse is reviewing the assessment findings for each of the children. Which finding requires the nurse to intervene? 9-month-old infant who can pull self up to a standing position 14-month-old toddler who walks with a parent's assistance 24-month-old toddler who engages in parallel play 3-year-old preschool-aged child who goes up stairs on hands and knees

3-year-old preschool-aged child who goes up stairs on hands and knees

A nurse is obtaining a weight on a 7-year-old who weighed 8 pounds at birth. How much does the nurse anticipate that he should weigh now? 42 pounds 84 pounds 62 pounds 56 pounds

56 By age 7, the child weighs about seven times as much as at birth

What finding would the nurse most likely discover in a 10-year-old child in the period of concrete operational thought? Participation in abstract thinking Ability to classify similar objects Problem solving via the scientific method Ability to make independent decisions

Ability to classify similar objects Another important change in thinking during this period is classification, the ability to group objects into a hierarchical arrangement (grouping by some common system).

Parents say they have been using measures to lessen the struggle of getting their preschooler to bed at night and to sleep. Which practice will the nurse suggest they discontinue? Allowing the preschooler to fall asleep wherever and whenever the child is tired enough Eliminating caffeine sources beginning late afternoon Providing a nightlight Taking the TV set out of the child's room Planning for the child to get 12 hours of sleep daily

Allowing the preschooler to fall asleep wherever and whenever the child is tired enough

The nurse is providing client education to the parent about bathing the infant. What would be important to instruct the parent? Infants need a daily bath Soap lubricates and oils an infant's skin Bath time provides an opportunity for play Never use soap on an infant's hair

Bath time provides an opportunity for play

The nurse is providing anticipatory guidance for parents of a preschooler regarding sex education. What is a recommended guideline when dealing with this issue? Be prepared to thoroughly cover a topic before the child asks about it. Before answering questions, find out what the child thinks about the subject. Expand upon the topic when answering questions to prevent further confusion. Provide a less than honest response to shelter the child from knowledge that is too advanced.

Before answering questions, find out what the child thinks about the subject.

The parent of an infant asks the nurse when to begin brushing the infant's teeth. What would be the nurse's best response? as soon as the first tooth erupts by 12 months of age when weaning is complete as soon as the infant begins to eat fruit

as soon as the first tooth erupts

A nurse is working with a preceptor in a well-baby clinic that deals with children aged birth to 12 years old. During the routine physical assessment of a 2-year-old, the nurse identifies which finding as being abnormal for this age group? heart rate of 92 beats/min, regular respiration rate of 20 bpm, abdominal breathing noted blood pressure of 116/80 mm Hg wears diapers since not potty trained

blood pressure of 116/80 mm Hg

The school-age child develops the ability to recognize that if a block of clay is in a round ball and then is flattened, the shape changes but not the amount of clay. What understanding has this child developed? conservation decentration classification reversibility

conservation

The nurse is watching a 4-year-old child play with another preschool child. The children are playing a game with rules. The nurse notes that the child is demonstrating what type of play? cooperative play associative play parallel play dramatic play

cooperative play

Which immunization would the nurse expect to administer at a preschool health maintenance visit? diphtheria, pertussis, and tetanus (DTaP) booster hepatitis B meningococcal disease tetanus booster

diphtheria, pertussis, and tetanus (DTaP) booster

A nurse is describing growth and development during the preschool period. What would the nurse identify as a predominant and heightened characteristic for this age group? imagination vocabulary gross motor skills fine motor skills

imagination

In observing a group of young adolescents playing basketball, it is noted that many of the adolescents appear to be uncoordinated and drop the ball often. The most common reason this occurs is because: large muscles grow before small muscles grow. hormone levels affect the motor skills of the adolescent. movements are voluntary and the adolescent has trouble focusing. fine motor skills have not yet begun to develop,

large muscles grow before small muscles grow.

Nurses should provide anticipatory guidance to males to prepare them for what particular pubertal change in middle-to-late adolescence? nocturnal emissions lengthening of the penis reddening of the scrotum pubic hair growth

nocturnal emissions Boys who start their growth spurts later are often concerned about being shorter than their peers. In boys, the appearance of nocturnal emissions ("wet dreams") is often used as the indication that the preadolescent period has ended.

A pediatric nurse observes an infant holding a rattle. Upon dropping the rattle, the baby cannot pick it up with his fingers on his own. The nurse correctly identifies this to be an example of which type of growth? abnormal growth abnormal development cephalocaudal proximodistal

proximodistal

During a well-child visit to the health care provider, the parent reveals a family struggling with the changes from their "sweet, cuddly 16-month-old child" to that of a negative, more aggressive 2-year-old toddler. After the clinic visit, the nurse will document which priority nursing focus for this visit? ready for enhanced family coping potential risk for child abuse malfunctioning family coping impairment in family's resilience

ready for enhanced family coping

The nurse pulls the 5-month-old to sitting position from supine and notes head lag. The nurse's response is to: refer the infant for developmental and/or neurologic evaluation. conclude the earlier assessments carried out fatigued the infant. consider this a normal response for the age. suggest more awake tummy time for the child.

refer the infant for developmental and/or neurologic evaluation

A 9-year-old is hospitalized for a long-term illness. The best project to give her to help achieve her developmental task would be: a scrapbook that will take 3 weeks to complete. a puppet show that will take 2 weeks to plan. watching her favorite program on television. sewing a purse that will take one afternoon.

sewing a purse that will take one afternoon.

The nurse knows that barriers to the adolescent's health and successful achievement of the tasks of adolescence exist. What is the major barrier to health for this population? cultural socioeconomic marital status racial

socioeconomic

An adolescent is concerned that although he has pubic hair, he has no facial hair yet. He wishes facial hair would grow to cover acne lesions. The nurse would advise him that facial hair: usually grows before pubic hair. is rarely present before 20 years of age. is delayed in boys with acne. usually follows pubic hair growth.

usually follows pubic hair growth.

The nurse is assessing the gross motor skills of an 8-year-old boy. Which interview question would facilitate this assessment? "Do you like to do puzzles?" "Do play any instruments?" "Do you participate in any sports?" "Do you like to construct models?"

"Do you participate in any sports?"

A nurse is providing health promotion education to a family of an 11-month-old infant who is eating "finger foods." The nurse knows the parents understand the risk of infant choking when they state which response below? "I can feed our baby Cheerios." "I can feed our baby popcorn." "I can feed our baby raisins." "I can feed our baby lollipops."

"I can feed our baby Cheerios."

During an annual visit of a 6-year-old boy, the nurse observes dental caries on two of the child's primary teeth. Which response by the parents suggests more education is needed regarding the importance of primary teeth? "These are only his baby teeth so we are not worried." "I guess we better look for a pediatric dentist for our son." "I guess we will need to supervise our son while he brushes." "I see now we need to use a fluoride toothpaste for our child."

"These are only his baby teeth so we are not worried."

The caregiver of 7-month-old twins tells the nurse that she has noticed that both of her children enjoy playing with a toy by moving the object back and forth between their hands over and over again. Which statement made by the nurse most accurately explains this behavior? "This is one of the ways that infants develop their fine motor skills." "Fine motor skills using the hands are mastered at approximately 7 months." "Development in nerve endings makes tactile activity more pleasurable at 7 months." "At 7 months the child can finally focus enough to follow objects with the eyes as he moves the object from hand to hand."

"This is one of the ways that infants develop their fine motor skills."

In providing anticipatory guidance related to choking hazards for infants, what should the nurse include in the teaching? Select all that apply. Propping a bottle Raw carrots Shape sorter Plastic bags Stuffed animals

Propping a bottle Raw carrots Plastic bags

The parent of a toddler indicates to the nurse that the toddler frequently yells, "No" to requests of the parent. What activity does the nurse recommend to the parent to increase additional vocabulary in the toddler? Playing toddler-friendly television shows Reading books to the toddler Telling the toddler to avoid using the word "No" Repeating the request again and with firmness

Reading books to the toddler

What suggestions regarding the evaluation of a childcare center would the nurse share with a preschooler's mother? A ratio of 10 children to 1 teacher is adequate. Specific program goals to be accomplished should be available. The longer the center has been in operation, the better it is. Research local newspapers to see if there are any complaints against the center.

Specific program goals to be accomplished should be available.

The nurse is assessing the development of a 15-month-old girl during a well-child visit. Which skill would the nurse expect to see? Feeds herself with a spoon Points to her nose and mouth Stands alone Runs to her mother

Stands alone

The parents of a preschooler express concern to the nurse about their son's new habit of masturbating. What is an appropriate response to this concern? Tell the child in a firm manner that this behavior is not acceptable. When the child displays this behavior, place him in a "time-out." Treat the action in a matter-of-fact manner, emphasizing safety. Consult a psychotherapist to determine the reason for this behavior.

Treat the action in a matter-of-fact manner, emphasizing safety.

The parents of a 30-month-old toddler have brought the toddler into the emergency department because of a seizure. During the health history, the nurse learns that the toddler was frustrated and angry immediately preceding the seizure. The nurse suspects the toddler had a breath-holding spell. Which parental report suggests breath-holding? A tantrum preceded the event. The event took place during a nap. The toddler was lethargic afterward. The toddler became unconscious.

A tantrum preceded the event.

A nurse working at a pediatric clinic includes an adolescent history for every child aged 11 to 18 years when the child is new to the office. Which issues should the nurse address when the parents are not in the room? Select all that apply. Job responsibilities Abuse/domestic violence Self-image Sexual activities Adolescent's fit in the family

Abuse/domestic violence Sexual activities

The parent of a 2-year-old toddler tells the nurse she needs to constantly scold the toddler for having wet pants. The parent says the toddler was potty trained at 12 months, but since starting to walk, the toddler wets the pants all the time. Which nursing diagnosis would be most applicable? Deficient parental knowledge related to inappropriate method for toilet training Excess fluid volume related to inability to control urination Ineffective coping related to lack of self-control of 2-year-old toddler Total urinary incontinence related to delayed toilet training

Deficient parental knowledge related to inappropriate method for toilet training

What is the appropriate time when children should be taught genitalia terminology and about personal privacy? Early childhood Middle childhood Late childhood Preadolescence

Early childhood

Which action would provide an indication that an adolescent's parents understand their child's need for increased independence? Verbalizing, "We try to do everything we can to make things easier for her." Reporting they understand that their child's chief need is for increased privacy Stating they are encouraging their child in the search for an after-school job Saying, "We will always be here for her whenever our child needs us."

Stating they are encouraging their child in the search for an after-school job

The nurse is caring for a 16-year-old adolescent who was arrested for driving while intoxicated. Which teaching method is mosteffective in changing the adolescent's behavior? Scolding the client for such irresponsible behavior Reviewing the long-term effects of alcohol on the liver Teaching that alcohol eventually will lead to other drug abuse Stressing that the driver's license can be lost if drinking continues

Stressing that the driver's license can be lost if drinking continues

Parents of a toddler describe how they handled their child's temper tantrum in a shopping mall. What action of the parents indicates need for additional teaching? Reasoned with the child to stop the behavior Tried to refocus the child's attention as tantrum behavioral cues appeared Made sure the child was rested and not hungry before going to the mall Remained relatively calm even though embarrassed

Reasoned with the child to stop the behavior

The nurse teaches parents of adolescents that teenagers need the support of parents and nurses to facilitate healthy lifestyles. What should be a priority focus of this guidance? Reducing risk-taking behavior Promoting adequate physical growth Maximizing learning potential Teaching personal hygiene routines

Reducing risk-taking behavior

The nurse is visiting a mother who has a 3-month-old infant. Which anticipatory guidance information should the nurse provide to the mother at this time? The child will have a fear of strangers. The child will experience many moody periods. The child will expect things to be done a certain way. The child should be able to turn over onto the back at age 4 months.

The child should be able to turn over onto the back at age 4 months.

A parent is distressed because the infant is on the 26th percentile for height and the 17th percentile for weight. What should the nurse teach the client? The child is healthy, provided the percentile for height exceeds that of weight. The child's position on a growth chart does not necessarily indicate a health problem. The infant is still heavier and longer than most other infants of the same age. The infant's pediatrician will be made aware of these findings promptly.

The child's position on a growth chart does not necessarily indicate a health problem.

The nurse observing toddlers in a day care center notes that they may be happy and pleasant one moment and overreact to limit setting the next minute by throwing a tantrum. What is the focus of the toddler's developmental task that is driving this behavior? The need for separation and control The need for love and belonging The need for safety and security The need for peer approval

The need for separation and control

The nurse is caring for a hospitalized 8-year-old child whose parents have been divorced. Which of the following is most important for the nurse to do for this child? The nurse should have clear information about who may contact the child. The nurse should interpret the child's feelings. The nurse should respect the child's wishes regarding the parents visiting. The nurse should introduce the child to other children from divorced families.

The nurse should have clear information about who may contact the child.

Like many 4-year-olds, Ethan is constantly seeking out and exploring new experiences and repeatedly asking his parents why-type questions. Ethan's behavior suggests that he is successfully navigating an important developmental task within the developmental theory of: Erikson Freud Kohlberg Fowler

erikson

What physiological changes would the nurse expect to address in a 10-year-old child? Select all that apply. eruption of permanent teeth pulse rate 70 to 80 bpm blood pressure 98/56 mm Hg 20/20 vision decreased immune globulins

eruption of permanent teeth pulse rate 70 to 80 bpm 20/20 vision

An 8-year-old boy who says he wants to be a doctor when he grows up pleads with the nurse to let him put on his own band-aid after receiving an injection. The nurse agrees and watches as the boy very carefully lines the band-aid up with the mark left by the injection and applies it to his skin. Then he asks, "Did I do it right?" and waits eagerly for the nurse's feedback. The nurse recognizes in this situation the boy's attempt to master the primary developmental step of school age. What is that step? Industry Perfectionism Accommodation Conservation

industry Erikson's developmental task for this age group is industry versus inferiority. Children who are unsuccessful in completing activities during this stage, whether from physical, social, or cognitive disadvantages, develop a feeling of inferiority.

Parents of a toddler are expressing concern about their child's extreme negativism. Every question is answered with a forceful, "no." Which information would be most appropriate for the nurse to share with this couple about their toddler's negativity? Select all that apply. This is not only normal for toddlers but demonstrates a positive stage of development. This is a step in the child's development toward independence and to take care of his or her own needs. After one warning, place the child in time-out if they say "no" again in response to questions. With regards to bath time, ask the child "Will you please go get ready to take your bath?" Rather than ask, "Do you want to come to dinner now?" instead state, "It's dinner time. Do you want to drink milk or water with your dinner

This is not only normal for toddlers but demonstrates a positive stage of development. This is a step in the child's development toward independence and to take care of his or her own needs. Rather than ask, "Do you want to come to dinner now?" instead state, "It's dinner time. Do you want to drink milk or water with your dinner?"