270 exam 4
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Conceal IV tubing with gauze wrap Request a sedative from health care provider Ask visiting family member to stay Assure bed alarms are activated
Conceal IV tubing with gauze wrap Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.
A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide? Administer a laxative. Call 911. Dilute with water or milk. Induce vomiting.
Dilute with water or milk.
Is the following statement True or False? Fine motor skills develop in a cephalocaudal fashion (from the center to the periphery)
False. Fine motor skills develop in a proximodistal fashion (from the center to the periphery). Gross motor skills develop in a cephalocaudal fashion (from the head to the tail).
A second trend occurring with growth and development of the infant states that development is proximodistal. This means: As nerve pathways develop, they become more specialized. All humans experience the same growth patterns. Both sides of the body grow equally. Growth progresses from gross motor movements to fine motor movements.
Growth progresses from gross motor movements to fine motor movements.
When educating families on fire safety in the home, which information is important for the nurse to emphasize? Account for all members and then exit together. Have a meeting place outside the home in case of fire. Keep a fire extinguisher in a closet. Use extension cords to prevent shock.
Have a meeting place outside the home in case of fire.
Is the following statement True or False? Suicide is the third leading cause of death in adolescents 15 to 19 years of age.
True. Suicide is the third leading cause of death in adolescents 15 to 19 years of age. In a nationwide CDC study, 15% of adolescents surveyed reported that they had seriously considered suicide within the past 12 months, with 11% creating a plan and 7% attempting to take their own life (CDC, 2014a).
The nurse is assessing a 15-year-old who was involved in a fight at school. Which client statements would the nurse see as evidence that this child is delayed in Erickson's developmental stages? Select all that apply. "I do not trust anyone." "I want to decide what I do with my life." "I am not good at anything." "I am strong and I want to protect people." "I really don't have many friends, nobody likes me."
"I do not trust anyone." "I am not good at anything." "I really don't have many friends, nobody likes me."
A client says, "I thought my period was late because I was drinking heavily and did cocaine a couple of times lately. But my pregnancy test is positive and I am scared about what I may have done to the baby." What information should the nurse provide about the possible effects of substance use on the baby? Select all that apply. "Your baby may be born prematurely." "There is a risk for birth defects in the baby." "As long as you were eating well, the baby is probably fine." "There is a risk the baby will be born with a low birth weight." "The medical care you get now can reverse any damage."
"There is a risk for birth defects in the baby." "There is a risk the baby will be born with a low birth weight." "Your baby may be born prematurely."
A nurse is working in a pediatric clinic. The parent has brought in the 2-year-old toddler for a well-child checkup. The parent asks what the common health problems are common for this age. The nurse's correct reply includes which of the following? Accidents Scoliosis Food allergies Lice infestation
Accidents
Tell whether the following statement is true or false. A nurse whose behavior is reasonable and prudent and similar to the behavior that would be expected of another nurse in similar circumstances is still likely to be found liable if a patient falls.
Answer: B. False Rationale: A nurse whose behavior is reasonable and prudent and similar to the behavior that would be expected of another nurse in similar circumstances is unlikely to be found liable if a patient falls, even if injury occurs.
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. Quality improvement (QI) Revamping the licensing requirements for foreign-educated nurses Establishment of clinical career ladders Teamwork and collaboration Client-centered care
Client-centered care Teamwork and collaboration Quality improvement (QI)
A nurse is teaching a 7-year old diabetic child who is in Piaget's concrete operational stage about insulin injections. Based on Piaget's theory, what would be the nurse's best method of preparation for this child? Demonstrate the procedure on a teddy bear. Give the child a pamphlet on diabetes to read. Explain the procedure to the child in detail. Show the child a video about diabetes and insulin.
Demonstrate the procedure on a teddy bear.
Is the following statement True or False? The best type of toys for toddlers is store-bought interactive electronic toys.
False. Toddlers do not need store-bought expensive toys. The best toys for toddlers are familiar household items, child-sized household items, blocks, cars, plastic figures, stuffed animals, dolls, doll beds, and carriages. Manipulative toys with knobs and buttons that make things happen, shapes to insert into matching holes, puzzles, chalk, buckets and shovels, and floating toys are also recommended. Appropriate gross motor toys include gyms, tricycles, pull toys, and wagons.
What are the two factors that drive growth and development? Genetics and environment Nutrition and exercise Environment and fertility Healthcare and perception
Genetics and environment
The parents of a 4-year-old girl bring the child to the clinic for the first time. During the assessment, the nurse asks the parents about any religious beliefs. The parents tell the nurse that they are Christian. The mother says, "We take her to church with us. She's really well-behaved. She even tries to imitate what we do, standing, kneeling, folding her hands, and such." The nurse interprets this behavior as reflecting which stage of faith development? Mythical-literal faith Undifferentiated faith Synthetic-conventional faith Intuitive-projective faith
Intuitive-projective faith
According to Kohlberg, which of the following considerations is central to human development? Agency Morality Safety Influence
Morality Kohlberg's theory of development focuses specifically on the changes in morality that occur over time. Kohlberg's Theory of Moral Development includes three levels: preconventional morality, conventional morality, and post-conventional morality.
As a nursing student is visiting a day care to observe growth and development in action. The nursing student completes assessments on infants and toddlers who are learning to walk, talk, and control elimination. According to Freud, in what developmental stage are they? Trust versus mistrust Relationships and events Phallic; genital Oral; anal
Oral; anal
A mother, 13 years of age, delivers a low-birth-weight neonate. The neonate is transferred to the neonatal intensive care unit. The mother reports receiving occasional prenatal care and has a history of excessive alcohol consumption. The growth and development of this neonate has been influenced by which of the following? Spiritual factors Individual factors Prenatal factors Caregiver factors
Prenatal factors
A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? Confine the fire. Evacuate the unit. Extinguish the fire. Pull the fire alarm lever.
Pull the fire alarm lever.
The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? Altered Sensory Perception related to decreased visual acuity Risk for Poisoning related to poor eyesight and the inability to read medication labels Risk for Falls related to immobility Risk for Injury related to substance use
Risk for Poisoning related to poor eyesight and the inability to read medication labels
While assessing a young adult client, the nurse asks the client what she would do in a certain situation. The client responds by describing actions that would be considered socially acceptable. Applying Freud's theory, the nurse interprets the response as reflecting which component of the mind? Ego Superego Unconscious mind Id
Superego
A nurse is presenting a workshop for a group of young women. Part of the workshop focuses on the moral development of women. The nurse integrates information about Gilligan's theory into the presentation, describing the various levels that a woman goes through as morality develops. When describing level 1, the nurse would focus on which area? Move from selfishness to responsibility Adoption of social values Acceptance by others Woman's own needs
Woman's own needs
According to Havighurst, learning behaviors are based upon developmental tasks. In assessing an adult patient, the nurse is aware that a common developmental task of middle adulthood includes: adjusting to retirement and reduced income. learning to live with a marriage partner. preparing for a career. assisting children to become responsible adults.
assisting children to become responsible adults.
The nurse is planning a diet for a toddler that is rich in vitamin A. Which of the following foods might the nurse include? a. avocados b. corn c. strawberries d. spinach
d. spinach Spinach is rich in vitamin A. Avocados are rich in folate, corn is rich in fiber, and strawberries are rich in vitamin C. Other foods rich in vitamin A include apricots, cantaloupe, carrots, mangoes, dark greens, and sweet potatoes.
The nurse assesses that a 2-year-old child begins to smile, wave his arms and legs, and vocalize when the child sees the parent setting up the high chair for lunch. The nurse determines this action as an indicator of progress in which of Piaget's cognitive stages? preoperational concrete operational formal operational sensorimotor
sensorimotor In the sensorimotor stage the child begins to reason and anticipate events. The remaining stages do represent stages of Piaget's cognitive stages; however, these do not represent stages in which the child begins to reason and anticipate events.
The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? the 2-year-old leaning against the screen of a window in a classroom the 2-year-old and 6-year-old each holding the mother's hand the 6-year-old riding a bike on the playground with his friend the 2-year-old helping mom to open the front door of the school
the 2-year-old leaning against the screen of a window in a classroom
A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error? "Have the client and the family been informed about this?" "How did the nurse's actions contribute to this error?" "How have other organizations responded to nurses in events like this?" "What is the organization's legal liability in this matter?"
"How did the nurse's actions contribute to this error?"
A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? "The chin strap on the helmet should be adjusted to fit loosely so that it does not choke the child." "Young children secured in a bicycle passenger seat do not have to wear a helmet." "Parents are effective role models for children when they also wear helmets while riding." "Any helmet is appropriate for bicycle riding because all children should wear helmets when riding."
"Parents are effective role models for children when they also wear helmets while riding."
A nurse is providing care to several children at the local clinic. When assessing each child, in which child would the nurse expect to find the ability to think abstractly and use deductive reasoning? 5-year-old female 3-year-old male 8-year-old male 13-year-old female
13-year-old female
The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use? 25-year-old female who just accepted her first job 34-year-old male who does not use a seat belt 40-year-old female who is working two jobs 19-year-old male college student majoring in physics
19-year-old male college student majoring in physics Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use.
The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention? Notify the interdisciplinary health care team to use nonlatex equipment. Teach the client to wear a Medic-Alert bracelet. Apply an allergy-alert identification bracelet on the client. Flag the room door.
Apply an allergy-alert identification bracelet on the client. The priority is to apply an allergy-alert bracelet to the client so that any member of the interdisciplinary team can quickly identify the latex allergy. All other actions can take place immediately thereafter.
A 25-year-old client is a college graduate and is married with one child. During a wellness visit, the client confides, "I just feel like something is missing from my life. Maybe I need to make a career change." How would the nurse familiar with Levenson and associates' theory of development interpret this statement? As a normal finding for a client at this stage of development. As indication that the client is lagging in developmental tasks. As indicating this client is advanced in thinking through life development. As a danger sign that the client is about to undergo a damaging transformation.
As a normal finding for a client at this stage of development.
Donald, a newly graduated nurse, is working in a pediatric clinic. Today he sees Karen, a 1-month-old infant, and her single mother. The mother is estranged from Karen's father but is marrying her high school sweetheart next week. Donald remembers from nursing school that which of the following will affect an infant's growth and development? Choose all that apply. Mother's prenatal nutrition Environment of infant Mother's gender identity Genetics of mother Father's gender identity
Genetics of mother Environment of infant Mother's prenatal nutrition
The nurse is assessing the cognitive development of an adolescent. Which of the following statements accurately represents a normal finding at this stage? a. the adolescent progresses from an abstract to a concrete framework of thinking b. the adolescent develops the ability to think outside the present c. all adolescents achieve formal operational reasoning at the same time d. adolescent thinking starts out very introspective and then becomes egocentric
b. the adolescent develops the ability to think outside the present. According to Piaget, the adolescent progresses from a concrete framework of thinking to an abstract one. During this period, the adolescent develops the ability to think outside of the present; that is, he or she can incorporate into thinking concepts that do exist as well as concepts that might exist. Not all adolescents achieve formal operational reasoning at the same time. Adolescent thinking starts out egocentric and then becomes very introspective and idealistic.
The nurse is assessing a 5-year-old child for signs of developmental delay. Which would alert the nurse to a potential problem? a. the child can build a tower of six blocks b. the child does not play with other children c. the child engages in fantasy play d. the child separates from parent easily
b. the child does not play with other children This is a sign of a potential developmental delay. Signs of developmental delay in preschool-aged children include not playing with other children, not being able to build a block tower of six to eight blocks, not engaging in fantasy play, and not separating from the parent without major protest.
An administrative assistant at a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has: a fracture of the hand. an infection in the bone. carpal tunnel syndrome. a herniated cervical disc.
carpal tunnel syndrome.
The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response? "Adjust sleeping schedules so that you can monitor your loved one as they sleep." "I know, my parent has Alzheimer's disease and I worry about that too." "Clients with Alzheimer's disease often wander." "Consider the Alzheimer's Association 'Safe Return' program."
"Consider the Alzheimer's Association 'Safe Return' program."
Which statement by a client would indicate that a nurse had successfully implemented an educational strategy to prevent injury in the home? "I have taken a CPR and first aid class." "I have removed all throw rugs on the floor." "I turn off the outside lights and lock the doors every night." "I place my phone next to my bed during the night for emergencies."
"I have removed all throw rugs on the floor."
Tell whether the following statement is true or false. A side rail is considered a restraint even if the patient asks for it to be raised to assist in getting into and out of bed.
Answer: B. False Rationale: A side rail is not considered a restraint if the patient requests that it be raised to aid in getting in or out of bed. Some patients may request that side rails be used at night while they sleep so that they may feel more secure. The patient must be able to raise and lower the side rail on one's own.
Tell whether the following statement is true or false. Among older adults, fires are the leading cause of injury fatality.
Answer: B. False Rationale: Among adults older, falls are the leading cause of injury fatality.
The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? Ask to examine the client alone in order to speak to her privately. Nothing, as it is none of the nurse's concern. Document the observed behaviors in the client's chart. Report the suspicions to the authorities.
Ask to examine the client alone in order to speak to her privately.
What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States? American Medical Association Centers for Disease Control and Prevention World Health Organization American Nurses Association
Centers for Disease Control and Prevention
A nurse is administering a scheduled medication to a client using the institution's bar code system. The nurse has scanned the client's armband as well as the scheduled medication. The system has signaled a discrepancy between the dose prescribed and the dose scanned. What is the nurse's most appropriate response? Consult with a colleague and identify the source of the error signal before proceeding. Document the discrepancy and place the medication on hold until the next scheduled dose. Consult the client's medication prescription and then administer the dose originally poured. Administer the dose specified by the computer system and document the event.
Consult with a colleague and identify the source of the error signal before proceeding.
A student nurse is assisting the school nurse with a health fair at a middle school. The student nurse assesses the students' height and weight as they file through her station, where she observes that there is a large variation in physical size and emotional maturity. Which of the following factors may affect physical growth of children? Choose all that apply. Availability of books Prenatal nutrition Colorful toys Heredity Physical activity
Heredity Prenatal nutrition Physical activity
Which developmental theorist created the psychosocial theory of development? Piaget Maslow Freud Erikson
Erikson
Is the following statement True or False? The school nurse conducting a vision screening program identifies a child with amblyopia. This condition occurs due to malalignment of the eyes.
False. Amblyopia or lazy eye, occurs due to one eye being more nearsighted, farsighted, or astigmatic than the other eye. Malalignment of the eyes causes a condition known as strabismus.
Tell whether the following statement is True or False. The nurse is counseling parents of a 5-year-old who are concerned that their child is masturbating. The recommended intervention for this situation is to advise parents to discourage their child from this practice using firm discipline.
False. The recommended intervention for a 5-year-old child who is masturbating is to treat it in a matter-of-fact way, making sure the child knows nudity and masturbation are not acceptable in public. If parents overreact to this behavior, it may occur more frequently. The child should also be taught that no other person can touch his or her private parts.
Is the following statement True or False? The school-age child's peer group values usually dominate when parental and peer group values come into conflict.
False. The school-age child's family values usually dominate when parental and peer group values come into conflict. Although the peer group is influential, the family's values usually predominate when parental and peer group values come into conflict. Even though the school-age child may question the parents' values, the child will usually incorporate the values from parents into his or her values.
A nurse asks a young adult questions about family, friends, and support systems based on Erikson's stages of psychosocial development. What is the reason this information is important during assessments of young adults? Without peer acceptance, the young adult will revert back to previous behaviors. Fear of commitments may lead to loneliness and isolation. Overprotection by parents may result in feelings of shame and doubt. Restrictions on new experiences may lead to feelings of guilt.
Fear of commitments may lead to loneliness and isolation.
A 10-year-old girl is excited when she receives the "most improved player" award on her softball team. Although she was not the strongest player on the team, she always tried to perform at her best level and never gave up on practicing her skills. What stage of psychosocial development according to Erik Erikson is this child demonstrating? Autonomy versus shame and doubt Initiative versus guilt Identity versus role confusion Industry versus inferiority
Industry versus inferiority
A nurse is caring for a child who stated, "Nobody likes me! I don't have any friends." According to Erik Erikson's Theories of Psychosocial Development, which of the following stages is the child at risk for not achieving? Autonomy vs Shame and Doubt Identity vs Role Confusion Initiative vs Guilt Industry vs Inferiority
Industry vs Inferiority
The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Administer the client's sedative as ordered. Contact the physician for a restraint order. Put up all four side rails on the bed. Initiate use of a bed alarm.
Initiate use of a bed alarm.
A boy 8 years of age is looking at his father's razor and shaving cream in the bathroom medicine cabinet. He watches his father shave daily and asks his father when he will need to start shaving. This child is demonstrating characteristics common during which of Freud's psychoanalytic developmental stages? Phallic stage Genital stage Latency stage Anal stage
Latency stage
A nurse is working with young adults and assessing their moral development. The nurse relates which of the following theorists who developed the Theory of Moral Development? Sigmund Freud Lawrence Kohlberg Erik Erikson Robert Havighurst
Lawrence Kohlberg
The nurse is counseling a woman who states: "I'm never going to find a husband; every time I start dating I end up getting hurt. I'm not even going to try anymore." This woman is in what stage of Carol Gilligan's theory of moral development? Level 2—goodness Level 3—nonviolence Level 1—selfishness
Level 1—selfishness
The nurse is providing prenatal education for a group of pregnant teenagers. The nurse talks about substance use during pregnancy and relates that use to which possible newborn consequences? Select all that apply. Premature birth Congenital anomalies Low birth weight Development of mistrust Poor development of superego
Low birth weight Premature birth Congenital anomalies
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? Run the electrical cord of the pump under the carpet. Tape the electrical cord of the pump to the floor. Use an extension cord to provide freedom of movement. Obtain a three-prong grounded plug adapter.
Obtain a three-prong grounded plug adapter.
The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? Supervise your child on the changing table. Peer pressure causes children of this age to take risks. Buy protective sporting equipment. Place all household cleaners out of reach.
Peer pressure causes children of this age to take risks. Adolescents tend to be impulsive and take risks as a result of peer pressure, so this is important for the nurse to teach the adolescent. Buying protective sporting equipment, placing household cleaners out of reach, and supervising the child on the changing table are not age-appropriate teachings to include.
A student nurse is enrolled in a growth and development class. Which of the following Freudian stages should the student nurse recognize in a child with an increase in gender difference awareness? Phallic Stage Anal Stage Latency Stage Oral Stage
Phallic Stage
The registered nurse is caring for a client with a waist restraint. Which tasks should the nurse delegate safely to the unlicensed assistive personnel (UAP)? Select all that apply. Obtain, record, and report vital signs. Determine if the waist restraint is too tight. Provide a bedpan and pericare. Chart the skin findings during the 2-hour check. Assess the client's need to continue the waist restraint.
Provide a bedpan and pericare. Obtain, record, and report vital signs.
The nurse is seeing a male client 6 years of age in the clinic. As the nurse is measuring height and weight for the client, his mother comments on how coordinated he is becoming. The nurse knows that this increase in coordination is which of the following? Related to development A reflex Part of being prepubescent Due to growth
Related to development
A client who was receiving care on a psychiatric unit died by suicide at a time when nurses are known to have been handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event? Appropriately discipline the nurses who were participating in the shift change. Change the institution's policies regarding supervision of clients. Report the event to the Joint Commission. Inform local health care institutions about the event to promote safety.
Report the event to the Joint Commission.
A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? Rescue anyone who is in immediate danger. Activate the fire alarm on the unit. Evacuate clients and staff. Attempt to extinguish the fire.
Rescue anyone who is in immediate danger.
A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? Restrain the baby in a car seat. Give warm bottles of formula to the baby. Keep all pots and pans in lower cabinets. Lock all cabinets that contain cleaning supplies.
Restrain the baby in a car seat.
The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care? Chronic Confusion Related to Long-Standing Alcohol Use Impaired Bed Mobility Related to Muscle Wasting Noncompliance Related to Medication Regimen Risk for Injury Related to Agitation
Risk for Injury Related to Agitation The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints.
A nurse is observing a child pick up a rattler and shake it to hear a sound. The nurse understands that the child is considered to be in which of the following of Piaget's Cognitive Development stages? Sensorimotor stage Preoperational stage Formal Operational stage Concrete Operational stage
Sensorimotor stage
Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? Social pressure Normal rebellion Poor judgment Past experience
Social pressure
A nurse assesses the effect of the environment and nutrition on patients visiting a walk-in clinic in a low-income community. Which statements accurately describe these effects? (Select all that apply.) Substance abuse by a pregnant woman increases the risk for congenital anomalies in her developing fetus. Infants who are malnourished in utero develop the same amount of brain cells as infants who had adequate prenatal nutrition. An increased incidence of teenage pregnancy can be linked to substance abuse by adolescents. Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships. Failure to thrive cannot be linked to emotional deprivation. Child abuse can lead to deficits in physical development, but psychosocial development is not affected.
Substance abuse by a pregnant woman increases the risk for congenital anomalies in her developing fetus. Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships. An increased incidence of teenage pregnancy can be linked to substance abuse by adolescents.
The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Leave the restraints on and talk with her, explaining that she must calm down. Take the restraints off, stay with her, and talk gently to her. Sedate her with sleeping pills and leave the restraints on. Talk with the client's family about taking her home because she is out of control.
Take the restraints off, stay with her, and talk gently to her.
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? Select all that apply. The adolescent achieves emotional independence from parents. The adolescent learns to get along with peers. The adolescent achieves social and civic responsibility. The adolescent accepts his or her body and uses it effectively. The adolescent learns physical skills necessary for games. The adolescent acquires an ethical system as a guide to behavior.
The adolescent accepts his or her body and uses it effectively. The adolescent achieves emotional independence from parents. The adolescent acquires an ethical system as a guide to behavior.
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? The nurse should notify the primary care physician about the bruises. The nurse should contact the facility's social services department. The nurse should question the client about the source of the bruises. The nurse should request permission from the client to photograph the bruises.
The nurse should question the client about the source of the bruises.
A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should include a note on the client's chart that mentions the report. The nurse should make a copy of the safety event report and place it in the client's medical record. The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse should await results of the x-ray before filing the report.
The nurse should record the incident in the client's medical record and fill out a safety event report separately.
A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? The report provides a detailed and objective account of the circumstances before, during, and after the event. The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration. The report becomes a confidential part of the client's health record once it is reviewed by hospital administration. The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed.
The report provides a detailed and objective account of the circumstances before, during, and after the event.
A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? Respond to the past history of the client (including previous falls) to determine the need for restraints. Individualize the use of restraints and choose the most easily used device. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse.
Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.
Is the following statement True or False? The nurse is assessing a 6-month-infant and obtains the following measurements: weight: 15 lb; length: 26 in; head circumference: 17 in. It has been determined that these are average measurements for a 6-month-old infant.
True. The following measurements: weight: 15 lb; length: 26 in; and head circumference: 17 in are average measurements for a 6-month-old infant. The average weight for a 6-month-old infant is 15 lb, the average length is 25 to 27 in, and the average head circumference is 16.5 to 17.5 in.
Is the following statement True or False? The nurse caring for an adolescent should teach the parents to monitor their adolescent's interaction with peer groups.
True. The nurse caring for an adolescent should teach the parents to monitor their adolescent's interaction with peer groups. Adolescents who do not have parental or adult supervision and opportunities for conversation with adults may be more susceptible to peer influences and at higher risk for poor peer selections.
Is the following statement True or False? The nurse should recommend that parents of a 3- to 5-year-old receive 500- to 800-mg calcium and 10-mg iron daily.
True. The preschool child needs 500- to 800-mg calcium and 10-mg iron daily. Preschool children need 500- to 800-mg calcium and 10-mg iron daily. Parents should be aware that drinking excess amounts of milk may lead to iron deficiency as the calcium in milk blocks iron absorption.
A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? a geriatric chair with a tray side rails a dose of an antipsychotic a dose of an analgesic
a dose of an antipsychotic
The nurse is assessing a 4-year-old for gross motor skill development. Which would the nurse expect this preschooler to have accomplished? a. hopping on one foot b. standing on one foot for 10 seconds c. skipping d. swimming
a. hopping on one foot The 4-year-old should be able to hop on one foot. At age 4, the preschooler hops on one foot and stands on one foot up to 5 seconds. At 5 years old the preschooler stands on one foot for 10 seconds, may skip, and may learn to skate and swim.
The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate? articulating the reason for use of a physical restrictive device to the client's spouse asking the unlicensed assistive personnel (UAP) to sit with the client application of devices that reduce the client's ability to move arms administration of an antipsychotic agent to alter the client's behavior
administration of an antipsychotic agent to alter the client's behavior
The nurses on a critical care unit can utilize the safety strategy of redundancy by: having two nurses independently check the dosage of high-risk medications. ensuring the antidotes are readily available for certain high-risk medications. introducing equipment that makes it more difficult for a nurse to commit an error. introducing a brief waiting period between the time that a medication is ordered and the time that it is administered.
having two nurses independently check the dosage of high-risk medications.
The nurse praises a 3-year-old child for using the potty. Which of the following theorists focuses on the satisfaction/frustration of expelling feces? a. Piaget b. Freud c. Erikson d. Kohlberg
b. Freud Freud's theory focuses on the satisfaction and/or frustration of expelling feces (anal stage). Piaget's theory focuses on development of the senses of the toddler; Erikson's theory focuses on achievement of autonomy and self-control; Kohlberg's theory focuses on the moral development of the toddler.
The nurse is planning a diet for a 30-kg school-age child. How many calories should the nurse include in the daily menu? a. 1,400 b. 1,750 c. 2,100 d. 2,450
c. 2,100 A 30-kg school-age child should consume 2,100 calories/day. Rational: The school-age child should consume 70 calories/kg daily (70 calories × 30 kg = 2,100 calories).
The nurse is assessing developmental milestones for a 7-month-old premature infant born at 28 weeks' gestation. What would be the adjusted age upon which the nurse would base the assessment? a. 2 months b. 3 months c. 4 months d. 5 months
c. 4 months The nurse assessing developmental milestones for a 7-month-old premature infant born at 28 weeks' gestation would adjust the age to 4 months. The infant was born 12 weeks early (3 months); therefore, the nurse would subtract 3 months from the chronologic age of 7 months to obtain an adjusted age of 4 months. Healthy growth would be demonstrated if the infant were the size of a 4-month-old and achieved the developmental milestones of a 4-month-old.
Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning? hidden sources of lead in the household environment keeping medications in clearly labeled containers alternatives to chemical-based cleaning supplies avoiding the use of alternative and complementary therapies
keeping medications in clearly labeled containers