Ch 9, 10, 12

The nurse is caring for a 7-year-old client. The nurse is providing education to the client about receiving vaccinations. Which is an appropriate action for the nurse to take when teaching the client?

Allow the client to model giving vaccinations on a teddy bear

A nurse is caring for a client whose primary language is different from the nurse. The client needs preoperative. The nurse best demonstrates a caring demeanor through which of the following actions?

Arranging for an interpreter or translator to be present

The nurse provides care to a patient who is actively dying. The patient's spouse is upset about her husband's respirations. Which response by the nurse is appropriate when providing education to the spouse about Cheyne-Stokes respirations?

As your husband approaches end of life, breathing will be a cycle of shallow and deep respirations

The nurse provides care to a toddler-aged client who is hospitalized. Which intervention does the nurse implement to promote the toddler's autonomy?

Asking the child to choose between chocolate or vanilla pudding

A client has just been diagnosed with terminal lung cancer. When the client becomes visibly upset, the nurse sits quietly with the client. In doing this, the nurse best demonstrates an understanding of which of the following?

Assessing client readiness to learn

What are the four stages of cognitive development

1- Sensorimotor (0-2 years) 2- Preoperational (2-7 years) 3-Concrete-operational (7-11 years) 4-Formal Operations (11+ years)

Which scenario does the nurse identify as exemplifying the transition to concrete operational thought as explained by Piaget?

A child no longer believing that an adult dressed in a mouse suit is a giant mouse.

The nurse provides care to a patient who is actively dying. When planning care for this patient and the family, the nurse prioritizes interventions to address which physical change associated with the dying process to ease the family's anxiety?

Accumulation of secretions in the trachea

When conducting an in-service about weight reduction, a nurse recognizes that participants will have accomplished true learning when they are able to demonstrate that they can do which of the following?

Adhere to a healthier diet, Exercise three times per week, and Consume fewer processed foods

Trust v.s. Mistrust

Age 0-18months, learn to trust others

indentity vs role confusion

Age 12-18, seek sense of self and plan according to ones abilities

Intimacy vs. Isolation

Age 18-40, develop intimate relationships and choose a career

Autonomy vs. Shame/Doubt

Age 18months-3years, learn self-control and the ability to express oneself and cooperate

Initiative vs. Guilt

Age 3-5, initiate activities and influence environment

Generativity vs. Stagnation

Age 40-65, become a productive member of society and establish a family

Industry vs. Inferiority

Age 5-12, develop sense of social skills and self-esteem

integrity vs despair

Age 65+, accept worth, uniqueness, and death

Which statement is inappropriate for the nurse to say prior to administering an intramuscular analgesic medication to a school-age child?

"My injections don't hurt.

The mother of a 1-year-old child asks a nurse how much her child should weigh. At birth, the child weighed 7 pounds and 8 ounces. Based on this information, the nurse tells the mother the child should be which weight?

22.5 pounds

The mother of a 9-year-old boy is concerned that her son is gaining weight too quickly for his age. Which is the range of weight gain that is expected during the ages of 5 and 12 years that the nurse shares with this mother?

4.5 to 6.5 pounds per year

The nurse provides care to a patient who is dying of colon cancer who states, "I know I can beat this cancer if I just change the things that I eat." Based on Kübler-Ross' stages of grief, which stage does the nurse document in the medical record that the patient is experiencing?

Bargaining

The nurse provides care to a terminal patient who states, "I don't need anything from you. Leave me alone!" Based on this information, the nurse documents that the patient is likely experiencing which stage of grief?

Bargaining

The nurse provides care to a patient who has died. Which action does the nurse implement when preforming postmortem care?

Bathe the patient's body and remove all tubes, unless an autopsy is prescribed

The nurse provides care to a terminally ill patient. Upon entering the patient's room, the nurse notes the patient is not breathing. The patient does not have a do-not-resuscitate (DNR) prescription. Which action does the nurse implement based on the current data?

Begin cardiopulmonary resuscitation (CPR) because a DNR prescription is not written

The nurse provides care to a terminally ill patient. The patient's family asks the nurse what should be expected during the dying process. Which response by the nurse is accurate and appropriate?

Breathing will stop, and then the heart will cease beating within a few minutes

The nurse is caring for a client with diabetes who has just been educated on how to monitor and manage blood glucose levels. Which questions asked by the nurse will effectively evaluate the client's understanding?

Can you show me how to use your blood glucose machine?, Can you explain what actions to take if your blood glucose is low?, What will you do if your blood glucose is too high?, and How do you dispose of used insulin needles?

A nurse is caring for a client who requires teaching about a heart-healthy diet. The client states that she is a visual learner. When selecting handouts for the client to read, the nurse ensures the handouts:

Clearly define medical terms

psychosocial development

Distinct stages and tasks for psychosocial development developed by Erik Erickson

The nurse prepares to perform postmortem care on a patient who passed away. Which step does the nurse implement for safety during this procedure?

Donning gloves

A nurse is caring for a client who is newly diagnosed with Graves disease. The nurse selects the nursing diagnosis "Readiness for enhanced knowledge." What should the nurse do next?

Create a written teaching plan

A nurse is caring for a client who is newly diagnosed with type 2 diabetes mellitus. The client requires teaching about antidiabetic medications, including when to take them, what effects are expected, and negative side effects to report if they occur. Which nursing diagnosis does the LPN/LVN expect to be used for this client?

Deficient knowledge

When asked by family members of a terminally ill patient what benefit their loved one would experience as a result of dehydration, a nurse explains that which of the following is true?

Dehydration will contribute to less edema and discomfort from ascites, Urinary output decreases, which results in less discomfort from toileting, and Dehydration increases endorphin production and decreases perception of pain

When providing care to a patient diagnosed with a terminal illness, which traditional first stage of grief does the nurse not anticipate the patient will exhibit?

Denial

The nurse gathers data for a pediatric client who is experiencing a developmental delay. Which question does the nurse ask to determine if the delay is due to biological factors?

Did your child experience a lack of oxygen during the birth process?

The nurse provides care to a terminally ill patient who has barely eaten anything for several days. Which nursing action is appropriate for this patient?

Encourage the patient to eat whatever foods he or she thinks sound and look appealing

A young adult brags to a nurse stating, "I never get sick and have not needed to see a doctor in years." Which frequency does the nurse recommend for the client to receive physical examinations and screenings even when feeling healthy?

Every year

When creating handouts for clients, a nurse should keep the handouts at the reading level of a ____________________ grader

Fifth

The nurse plans to reinforce education for an adolescent client. Which topics does the nurse include during the session?

Firearms, birth control, internet safety, and sexually transmitted infections

What are some influences on physical development?

Genetics, nutrition, and function of the endocrine and central nervous system

When educating a client, the nurse encourages the client to drink plenty of water and to exercise regularly. These are examples of ____________________.

Health promotion

The spouse of a dying patient states to the nurse, "I believe remorse for the dead leads to more suffering of the soul and will increase the soul's difficulty in leaving the earthly plane. I prefer to think only happy thoughts to facilitate the journey." Which culture does the nurse identify for the couple based on the spouse's statement?

Hindu

cognitive development

How we learn from birth to adolescence in an orderly sequence of four stages developed by piaget

A nursing instructor explains that for learning to truly take place, the information must be reinforced. A student demonstrates understanding by saying which of the following?

I must make sure several times that the client knows what medications will be prescribed

An LPN/LVN is assisting the RN in caring for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client cares for a spouse at home who also has COPD. When formulating a nursing diagnosis for this client, the RN selects "Readiness for enhanced knowledge." The RN sits down with the client and presents the information included in his or her teaching plan. Which step in the nursing process would this be considered?

Implementation

The nurse gathers data from a client who will be headed off to college in the fall. The client states, "I am developing my own spiritual beliefs that are different from my parents." According to Fowler, which stage of spiritual development does the nurse document in the client's medical record?

Individuating-reflexive

The nurse gathers data for a child who imitates the parents' behaviors about religion. Based on Fowler's Stages of Spiritual Development, which stage does the nurse document in the child's medical record?

Intuitive-projective

The nurse provides care for a patient who is actively dying. The patient's spouse tells the nurse, "I am worried that my husband is not getting enough fluids." Which response by the nurse is appropriate?

It is natural to become dehydrated before death. It will actually make him more comfortable

The nurse provides care to a patient who is prescribed palliative care. The patient asks, "What is the difference between hospice care and palliative care?" Which does the nurse include in the response to the patient regarding palliative care?

It may be aggressive and is directed at eliminating discomfort

A nurse instructs a postpartum client who wishes to breastfeed to gently touch the newborn's cheek that is closest to the breast to cause the baby to turn toward the breast and open the mouth to find milk. Which reflex is the nurse describing the client to elicit?

Rooting reflex

Which is the priority when providing care to the pediatric client?

Safety

The nurse gathers data for a child who is 8 years of age during a well-child visit. Which stage of development does the nurse document for this child in the medical record?

School-ager

A nurse is caring for a client with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse is teaching the client how to organize medications. The client notes that he is a ____________________ learner, so the nurse has the client physically place medications used to treat COPD in a pill organizer.

Kinesthetic

The nurse is preparing to teach a client how to take blood glucose levels. The client notes, "I'll understand this better if I do the task with your guidance." Which type of learner is the client?

Kinesthetic

A client who underwent a carotid endarterectomy asks a nurse about care for his neck incision. The client informs the nurse that he is an auditory learner. The nurse determines that the client will learn best by:

Listening to the nurse's verbal instructions about care of the incision

The nurse provides care to a patient who has a written document containing medical decisions should the patient be unable to make them as the illness progresses. Which end-of-life documentation does the patient have based on the current information?

Living will

An LPN/LVN assists with educating a client who has just been diagnosed with rheumatoid arthritis. The client asks where he can find information on the Internet. The nurse's best recommendation is to view which of the following sites?

Mayo Clinic's website and Websites ending in ".org" or ".gov"

During adolescence, girls develop breasts and boys develop facial hair. The nurse documents these findings as a normal stage of which type of development?

Moral

A patient's daughter approaches a nurse to explain that upon the death of a male, female nurses should not touch the body. The family also asks that the body remain completely covered with the feet turned toward Mecca. Based on the family's request, the nurse concludes that the family identifies with which faith?

Muslim

The nurse provides safety education to the parents of preschooler and school-age children. Which parental statement indicates to the nurse the need for additional teaching regarding the safety needs of these children?

My child's greatest safety risk is choking at this stage of development

The nurse reinforces education to a terminally ill patient and family regarding the senses. Which statement by a family member indicates correct understanding of the information presented?

My loved one's ability to hear is the last sense to go at end of life

A client has just been diagnosed with noninsulin-dependent diabetes mellitus (NIDDM). The client asks a nurse about potential complications related to his or her illness. The nurse states that it can lead to which of the following?

Nerve pain, Blindness, Heart disease, and Poor circulation

The nurse provides care to a terminal patient who is approaching end of life. Which information does the nurse reinforce with the family members as indicating death is very near?

Nonresponsiveness, slow and thready pulse, mottling of feet and legs, and edema of lower extremities

The nurse witnesses a terminally ill patient telling the health-care provider, "I don't want my life prolonged, as stated in my living will." Which action does the nurse anticipate from the health-care provider based on the patient's statement?

The provider will speak to the patient's family before writing a DNR prescription

Which patterns does the nurse include when providing an in-service to newly hired staff regarding growth?

Orderly, predictability, proximodistal, and cephalocaudal

A nurse is caring for a client who has been attending a local university to earn a law degree. The client states, "I want to earn my degree so that I can fight for justice and human rights for people throughout the world." The nurse recognizes that the client is in which stage of Lawrence Kohlberg's moral development theory?

Postconventional morality

An older adult patient becomes progressively more confused. The patient begins talking to long-gone loved ones about places and events that do not make any sense to the family. Which is the priority nursing action based on the current information?

Protect the patient from injury by bed rails or equipment

A nurse is caring for a visually impaired client who requires discharge instructions. When speaking with the client, the nurse should do which of the following?

Provide the client with larger-print handouts

Which of the following are examples of wellness strategies?

Providing tips on how to quit smoking, Emphasizing how to reduce the amount of unhealthy foods consumed, and Providing tips on changing how much alcohol one consumes

Children in preschool often learn from pretending, role-playing, and exploring the identities of adults in various positions, such as nurses, doctors, teachers, police officers, firefighters, and others who serve as role models. A nurse identifies this as an example of which type of behavior?

Psychosocial development

The nurse provides care to a patient who experiences dyspnea. The patient states, "I don't want to take any more medication." Which nonpharmacological intervention does the nurse implement for this patient?

Putting a fan near the bed to circulate the air

A client who is recovering from a myocardial infarction (MI) asks a nurse about following a heart-healthy diet. The client states that she is primarily a visual learner. Which activity will best help the client learn about a heart-healthy diet?

Reading a chapter in a book about a heart-healthy diet

The nurse reinforces education about motor vehicle safety to a young couple who is about to start a family. Which client statement indicates the need for additional teaching?

The use of a car seat becomes optional once the child grows out of the infant stage

Which action is best from the nurse when providing care to a toddler who throws a "temper tantrum" during a well-child visit?

Removing the toddler to a quiet place away from the situation

The nurse reinforces education for the family of a terminally ill patient. When discussing respite care with the family, which statement by a family member indicates correct understanding of the information?

Respite care means that I will be given an opportunity to have time away from my spouse without worrying about his care

The nurse observes an infant picking up items and immediately placing the items in the mouth. When documenting this observation, the nurse identifies that the infant is encouraging cognitive development through which concept?

Sensorimotor experiences

A terminally ill patient refuses to take adequate pain medication. The patient expresses worry that the use of pain medication may result in addiction. Which response by the nurse is appropriate?

Teach the patient that addiction is not a concern during the terminal stages of illness

The nurse determines that it is best to discuss with the client the benefits of mobility for all body systems during ambulation. This is an example of the nurse identifying a(n) ____________________.

Teachable moments

moral development

The ability to think at higher levels and develop a value system that differentiates right from wrong developed by Lawrence kohlberg

For clients who have been newly diagnosed with a disease, which of the following would receive the nursing diagnosis "Deficient knowledge"?

The client has never heard of the disease and The client does not understand the medications used to treat their disease

The nurse provides care to an older adult client who displays a fearful attitude toward the nurse when care is provided. The client has multiple unexplained bruises, and several old fractures appear on the x-ray that were never treated. Which does the nurse suspect based on the current data?

The client may have been abused by a caregiver

Physical Development

The physical size and functioning of a person

Which client statement indicates to the nurse the need for further instruction regarding expected age-related changes that occur during the older adult stage of development?

There will be a decrease in bone density.

The nurse provides care to a patient who is terminally ill. Which nursing action is the priority when providing care to this patient at the end of life?

Touching the patient to show caring

Which actions by the nurse are age-appropriate when providing care to a hospitalized adolescent?

Treating the adolescent with respect and Encourage the adolescent's peers to visit

A nurse is caring for a client who can speak and understand some English but is not fluent. The nurse should:

Use a professional or certified interpreter from the hospital's list of available interpreters

The nurse is caring for a client who is 75 years old. When teaching the client, the nurse should:

Use plenty of repetition

Which information does the nurse include in a teaching session for the school-age child regarding the prevention of accidents and injuries during this stage of development?

Water safety, sports safety, and escape from abduction

The nurse provides care to a terminally ill patient. Which patient response indicates to the nurse a readiness to talk about dying?

What do you think death feels like?

A nurse is supervising a student nurse. When providing client teaching, the nurse intervenes when the student nurse states which of the following?

Why didn't you do it the way that I showed you?