Chapter 17, 18, 19 - Growth & Development
The nurse is admitting a 14-month-old client to the pediatric floor with a diagnosis of croup. Which characteristics would the nurse expect if the toddler is developing normally?
A strong hand grasp is demonstrated within the first month of life. Holding one object while looking for another is accomplished by the 20th week. Within the first year of life, the toddler masters smiling at familiar faces and voices
A school nurse is using Havighurst's developmental theory to teach parents of adolescents what to expect at this developmental stage. Which behaviors are typical of adolescents?
Behaviors typical of adolescents would include acceptance of his or her body and use of it effectively, achieving emotional independence from parents, and acquiring an ethical system as a guide to behavior
The mother of a 17-year-old girl with Down syndrome tells the nurse that her daughter recently stated that she has a boyfriend. The mother is concerned that her daughter might become pregnant. Which is the most appropriate suggestion by the nurse?
Children with Down syndrome range from severely intellectual disability to low average intelligence, Thus the adolescent's ability to make informed choices regarding sexual activity is limited. Long-acting contraception, such as an intrauterine device or a progestin implant, greatly reduces the risk of unwanted pregnancy.
The nurse is caring for a man 79 years of age who was admitted for a hip replacement. He visits with the nurse every chance he gets; he seems lonely. He tells the nurse his wife died two years ago. He has children in nearby cities and has nine grandchildren. He says his life has been good and he is content, even though he misses his wife. The nurse assesses him for developmental issues and knows that he fits well into which of Erikson's stages of development?
Later adulthood brings either ego integrity or despair, according to Erikson. As one enters the older years, reminiscence about life events provides a sense of fulfillment and purpose. If one believes that one's life has been a series of failures or missed directions, a sense of despair might prevail.
A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include
One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness.
A nurse, who witnesses an accident involving an adolescent being thrown from a motorcycle, stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emergency medical service to arrive, what should the nurse do?
The adolescent's signs and symptoms suggest a spinal cord injury. A client with suspected spinal cord injury should not be moved until the spine has been immobilized.
The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the health care provider?
The changes suggest that the adolescent's intracranial pressure is increasing Cushing's triad (apnea, bradycardia, and widening pulse pressure) is a hallmark of increasing intracranial pressure, which indicates that the teen's condition is deteriorating.
5-year-old determines that his parents enforce discipline based upon his behavior. According to Piaget, what does this period represent?
The child from 4 to 7 years old uses heteronymous moral reasoning. This concept is one in which those outside the person determine rules and justice.
When assessing the health of a neonate, the nurse should be aware that
The neonate hears and turns toward sound and can smell and taste.The neonate's senses are used to respond to the environment; see color and form; hear and turn toward sound, smell, and taste; and feel touch and pain
When teaching parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction?
The nurse should encourage the parents of a child with a congenital heart defect to treat the child normally and allow self-limited activity
An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care?
White patches on the tongue and oral mucosa indicate infection; the adolescent should report the patches, not remove them.
A mother asks the nurse when she should wean her 4-month-old infant from breast-feeding and begin using a cup. What should the nurse explain as the best indication of the infant's readiness to be weaned?
decreased interest in nursing.Readiness for weaning is an individual matter but is usually indicated when an infant begins to decrease the time spent nursing and shows increased interest in what others are eating. The infant is then showing independence and will soon be ready to take a cup and learn a new skill.
A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother:
how the child's condition today differs from his normal condition.in order to identify the chief complaint
53s A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation fo
starting oxygen.The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy
The parent of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which measure should the nurse suggest?
Elevate the head of the child's bed. The child's swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face
A child is brought to the emergency department experiencing severe right lower quadrant pain. The child's pulse and respirations are elevated, and there are localized tenderness and sluggish bowel sounds. Shortly after the initial assessment, the child states that the pain has suddenly resolved. Which of the following would the nurse suspect?
When a child with severe right lower quadrant pain has a sudden relief of pain, a ruptured appendix should be suspected.
A nurse is caring for a client in a clinical setting. According to Havighurst, which of the following developmental tasks are for middle adulthood?
Havighurst's developmental tasks for middle adulthood include: Accepting and adjusting to physical changes, relating to one's spouse as a person, and assisting children to become responsible adults.