Funds- developmental stages

The parents of a 2 year old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2 year old child indicates which? 1. the child is withdrawn 2. the child is upset with the parents 3. the child is exhibiting a normal pattern 4. the child has adjusted to the hospitalized setting

3 Rationale: the toddler is particularly vulnerable to separation. a toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home. the parents of hospitalized toddlers are frequently distressed by such behavior. the toddler normally engages in parallel play and plays alongside (but not with) other children

The nurse is caring for a 5 year old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child? 1. blocks 2. a puzzle 3. a music video 4. large picture books

2 Rationale: in the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board games. puzzles are also appropriate and aid with fine motor development. blocks are most appropriate for the toddler. a music video is most appropriate for the adolescent. large picture books are most appropriate for the infant

Upon palpation of the fontanel of a 3 month old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take? 1. increase oral fluids 2. document the findings 3. notify the RN 4. elevate the head of bed to 90 degrees

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

When caring for a 3 year old child, the nurse should provide which toy for the child? 1. a puzzle 2. a wagon 3. a golf set 4. a farm set

2 Rationale: toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. toddlers need supervision at all times. push pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. a puzzle with large pieces only may be appropriate. a farm set and a golf set may contain items that the child could swallow

The ED nurse is reinforcing discharge instructions to the parents of a 2 year old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement? 1. we will be sure not to leave hot liquids unattended 2. i guess my child needs to understand what the word hot means 3. we will be sure that our child stays in his room when we work in the kitchen 4. we will install a safety gate as soon as we get home so that our child can't get into the kitchen

1 Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. pot handles should be turned inward and toward the middle of the stove. hot liquids should never be left unattended, and the toddler should always be supervised.

The parent of a 4 year old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response? 1. it is best to ignore the behavior 2. your child is acting like a baby 3. the doctor will need to be notified 4. a 4 year old is too old for this type of behavior

1 Rationale: in the hospitalized preschooler, it is best to accept regression if it occurs, because it is most often caused by the stress of the hospitalization. parents may be overly concerned about regression and should be told that their child may continue the behavior at home. there is no need to call the HCP

The parents of a 16 year old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response? 1. adolescents love to sleep late in the morning 2. the child shouldn't be staying up so late at night 3. if the child eats properly, that shouldn't be happening 4. the child should have a blood test to check for anemia

1 Rationale: the sleep patterns of the adolescent vary some according to individual needs. however, in general, adolescents love to sleep late in the morning, but they should be encourages to be responsible for waking themselves, particularly in time to get ready for school

Which interventions are appropriate for the care of an infant? SATA 1. provide swaddling 2. talk in a loud voice 3. provide the infant with a bottle of juice at naptime 4. hang mobiles with black and white contract designs 5. caress the infant while bathing or during diaper changes 6. allow the infant to cry for at least 10 minutes before responding

1, 4, 5 Rationale: holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. to provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. additional interventions include playing a music box, radio, or television or having a ticking clock or metronome nearby. hanging a bright, shiny object within 20 to 25cm of the infants face in the midline and hanging mobiles with contrasting colors (black and white) provide visual stimulation. crying is an infants way of communicating, therefore, the nurse would respond to the infants crying. the mother is taught to do so also. an infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk of nursing (bottle mouth) caries

The nurse is preparing to care for a dying client, and several family members are at the clinic's beside. Which therapeutic techniques should the nurse use when communicating with the family? SATA 1. discourage reminiscing 2. make the decisions for the family 3. encourage expression of feelings, concerns, and fears 4. explain everything that is happening to all family members. 5. touch and hold the clients or family members hand if appropriate 6. be honest and let the client and family know that they will not be abandoned by the nurse

3, 5, 6 Rationale: the nurse must determine whether there is a spokesperson for the family and how much the client and family wants to know. the nurse needs to allow the family and client the opportunity for informed choices and assist with the decision making process if asked. the nurse should encourage expression of feelings, concerns, and fears and reminiscing. the nurse needs to be honest and let the client and family know that they will not be abandoned. the nurse should touch and hold the clients or family members hand

A 16 year old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development? 1. encourage the child to rest and read 2. encourage the parents to room in with the child 3. allow the family to bring in favorite computer games 4. allow the child to participate in activities with other individuals in the same age group when the condition permits

4 Rationale: adolescents are not often sure they want their parents with them when they are hospitalized. because of the importance of the peer group, separation from friends is a source of anxiety. ideally, the peer group will support the ill friend