9-10

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

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 terminal patient who is approaching end of life. Which information does the nurse reinforce with the family members as indicating death is very near? Select all that apply.

Nonresponsiveness Slow and thready pulse Edema of lower extremity Mottling of feet and legs

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

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?

Anger

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 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 plans to reinforce education for an adolescent client. Which topics does the nurse include during the session? Select all that apply.

Internet safety Firearms Sexually transmitted infections Birth control

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 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.

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

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

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

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

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-aged

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 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 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.

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? Select all that apply.

Water safety Escape from abduction Sports safety

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 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 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 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 safety education to the parents 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."

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 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."

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 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

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.

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

"What do you think death feels like?"

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.

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? Select all that apply.

Dehydration will contribute to less edema and discomfort from ascites Urinary output decreases, which results in less discomfort from toileting. 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 prepares to perform postmortem care on a patient who passed away. Which step does the nurse implement for safety during this procedure?

Donning gloves

Which actions by the nurse are age-appropriate when providing care to a hospitalized adolescent? Select All that apply.

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

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

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

Physical

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

Which patterns does the nurse include when providing an in-service to newly hired staff regarding growth? Select all that apply.

Predictable Cephalocaudal Proximodistal Orderly

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.

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.

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