Chapter 22

A nurse is provding care to a 2 1/2-year-old girl recently admitted to the hospital for an exacerbation of asthma. When developing this child's care plan, which intervention would the nurse likely include?

Encouraging the parents to provide care to the child

The nurse is administering scheduled immunizations for a boy 18 months of age. The nurse would recognize that this child is most likely engaged in which of the following developmental tasks?

Expressing his autonomy

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.

A parent brings the 18-month-old to the clinic for treatment of a head cold. The child has been coughing for the last two days and nights. The parent says, "When my older kids were this age, the only thing that would stop their cough was a cough syrup containing codeine." How should the nurse respond?

We have discovered that codeine does not work well with young children."

A nurse is preparing to assess a newborn immediately after birth using the Apgar score. Which area would the nurse include in this assessment? Select all that apply.

Respiratory effort Color Heart rate Muscle tone

A nurse is caring for children in a children's hospital. Which child would the nurse expect to develop separation anxiety?

A newly hospitalized toddler

A nurse is counseling pregnant women about the detrimental effects of smoking and drinking on a fetus. During what stage of development is the fetus most susceptible to these teratogens?

Embryonic stage

Today the pediatric clinic nurse gets Mrs. Johnson and her 20-month-old son, Jackson, settled in an exam room. Mrs. Johnson tells the nurse that the biggest problem she faces now is Jackson's refusal to let her out of his sight. "He screams and cries if he thinks I am gone". She asks if she should be concerned about this. What is the nurse's best reply?

"Separation anxiety is normal at 18 to 24 months."

The school nurse is talking with a group of students about reports that someone has been stealing food from the cafeteria. Which initial statement would the nurse expect from a student who is an early adolescent?

"Stealing is wrong."

A school nurse is developing a safety class for high school students. In preparation for this class, the nurse has reviewed statistics regarding injuries in this age group. Which information will the nurse include? Select all that apply.

"The highest cause of death in your age group is some sort of injury." "Fatal motor vehicle accidents are more likely to occur if a teenager is driving." "Kids who use alcohol are more likely to also participate in risk-taking behaviors."

A nurse is providing education to a group of new parents about ways to minimize the risk for sudden infant death syndrome (SIDS). The nurse determines that the teaching was successful based on which statement by the group? Select all that apply.

"We should put our baby on the back to sleep." "The sleeping surface should be firm." "The crib should be free of any soft objects or toys."

free radical theory of aging

Aerobic respiration produces free oxygen radicals (superoxide anions) that damage DNA and proteins. Over time, the damage accumulates and leads to aging.

Which of the following statements explains how pregnancy affects the growth and development of the adolescent?

Affects the normal physical and maturation processes

A nurse is teaching a "Young Childcare" class and Bill, one of the parents, asks what kinds of new physical skills his 13-month-old son will be learning during the next 2 years. Which of the following responses would be appropriate? Choose all that apply.

Drinks from a cup Runs, kicks, climbs stairs Uses a spoon Walks forward and backward

A nurse is implementing a health/sex education program in a public school. With which grade level should the nurse begin the program?

Elementary

Which of the following nursing activities is the most significant in assisting with transitioning from the adolescent to the young adult age group?

Facilitating healthy family relationships

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about how the baby develops soon after conception. An accurate statement from you about the zygote and preembryonic stage would be which of the following?

Has a total of three distinct cell layers

A nurse is teaching a parenting class for parents with infants. What is an example of an appropriate teaching point for this developmental age?

If choking occurs, give back blows and chest thrusts or CPR.

A 9-year-old who is in the 3rd grade has great difficulty with reading. The child is becoming very withdrawn and depressed. According to Erik Erikson's developmental theory, the child is at risk for developing which self-concept?

Inferiority

A nurse is conducting a program for a group of parents who have preschoolers. The focus of the program is safety in this age group. The nurse would emphasize measures to address which potential source of injury? Select all that apply.

Motor vehicle crashes Drowning Burns Poisoning

Accurate instruction regarding the typical growth and development patterns for adolescents would include which of the following guidelines?

Peer relationships characterize the adolescent years.

A nurse is providing care to an adolescent recently hospitalized for a sports-related injury. When planning this client's care, which group would the nurse identify as being extremely important to him or her?

Peers

The school nurse is teaching parents of adolescents about the development of self-concept in their children. What would the nurse state is most influential in stabilizing self-concept in this age group?

Peers

A nurse is teaching a 2-week pregnant woman what is occurring in the development of her baby. What should the nurse educate the client that normally occurs in this preembryonic stage? Select all that apply.

The zygote implants in the uterine wall. Three distinct layers of cells exist.

At which stage of pregnancy is the developing fetus most at risk for developing congenital anomalies?

embryonic stage

A 6-month-old infant visits the pediatric clinic for a well-baby checkup. The infant's parent asks what the common health problems are for this age. What is the best response by the nurse?

food allergies.

A preschool child is hospitalized with an infection. The child refuses to eat anything but macaroni and cheese and ice cream. What is the nurse's best way of getting the child to eat more?

Rewarding the child with ice cream for eating more nutritious foods.

A nurse is assessing and diagnosing children in a pediatrician's office. Which diagnosis would be most appropriate for a school-age child?

Risk for infection

The nurse is educating a new parent about what type of physical activities the infant will be able to achieve in the first year. What activities will the nurse discuss with the parent? Select all that apply.

Stack building blocks Ambulation may start Crawl on all fours

A newborn is scheduled for a circumcision and the parent is concerned with the baby feeling pain. What is the best response by the nurse?

"Baby's feel the sensation of touch and pain."

A nurse is assessing a 12-month-old infant who is brought to the clinic by the parents for well-child visit. The nurse reviews the infant's health history and notes that the infant weighed 8 lb at birth. When assessing the infant's weight at this visit, the nurse would anticipate that the infant would weight approximately how much at this time?

24 lbs

When a nurse is working on a pediatric unit, which of the following clients would the nurse know has the greatest need for good nutrition?

5 month old

In which developmental stage are genetic malformations most likely to occur?

First trimester

The parents of a 4 month old cannot visit at the hospital except on weekends. Which of the following actions by the nurse indicates an understanding of the emotional needs of a young infant?

Assign the same nurse as much as possible

A nurse is assessing infants during regular visits to a pediatrician's office. What physical characteristics will the nurse identify when assessing the infants? Select all that apply.

Body temperature stabilizes. Eyes begin to focus and fixate. Heart rate slows and blood pressure rises.

A nurse is teaching parents of preschoolers about normal development for this age group. Which teaching points would the nurse include? Select all that apply.

By 6 years of age, the preschooler's head is close to adult size. The preschooler's body is less chubby and more coordinated. The preschooler is able to skip, jump, and throw a ball.

Which of the following behaviors demonstrated by a 6-year-old child would help the school nurse assess characteristics of attention deficit hyperactivity disorder (ADHD)?

Gets into fights in cafeteria Is easily distracted in class Does not sit still in class

A nurse is providing care to a female adolescent diagnosed with binge eating disorder. The nurse understands that which situation is most often associated as the underlying issue with this disorder?

Negative self-concept

The nurse is assessing a preschooler who has just turned 6 years of age. The nurse expects which of the following as typical development for a child in this developmental phase.

The head is close to adult size by age 6 years.

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks how the baby develops after the first trimester. An accurate statement from the nurse about the fetal stage would be which of the following?

The heartbeat can be heard

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks about how the baby develops soon after birth. An accurate statement from the nurse about neonatal development would be which of the following?

The neonate is able to hear and turn toward sound

While teaching a sex education class to a group of preadolescents, the school nurse explains that human growth and development begins at which of the following events?

When ovum is fertilized by sperm

The pregnant young adult asks the nurse when she will be able to hear the fetal heart beat. Which is the nurse's best response?

"At your 12-week appointment, you will be able to hear the heart beat by Doppler."

A nurse is providing care to a new mother who yesterday gave birth to a healthy neonate. The new mother asks, "I was reading that it's important to bond and attach with my baby. But is there a difference in the two?" Which response by the nurse demonstrates understanding of these two concepts?

"Bonding is the immediate connection you have with your baby while attachment occurs over the long term."

A nurse is teaching a "care of the infant" class and Kelly, one of the members, asks a question about how long her baby will be considered an "infant". Which of the following is the nurse's best response?

"From 1 month to 1 year"

A mother brings her 28-month old boy to the clinic for a well-child visit. During the visit, the mother tells the nurse, "Whenever I ask my child to do something, all I get is no. It seems like that's the only word he knows." Which response by the nurse would be most appropriate?

"His 'no' is his way of trying to gain control over his surroundings."

The mother of a girl 6 years of age is exasperated at her daughter's persistent enuresis. How can the nurse best respond to this mother's concern?

"Most children outgrow their bedwetting at around your daughter's age or shortly after."

A 9-year-old child has been admitted to the orthopedic unit for treatment of a fractured leg due to an all-terrain vehicle accident. What would be a priority concern experienced by the child during hospitalization?

Absence from school and activities

A nurse at the health center is reviewing the health records of several of the clients who are scheduled for appointments today. The nurse identifies which client as being an adolescent? Select all that apply.

14-year-old with asthma 12-year-old who had an appendectomy

A nurse is teaching a "Preschool Childcare" class and Tiffany, one of the parents, asks when her toddler will have all of her baby teeth. Which of the following responses would be appropriate?

3 years

A nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks how the baby develops soon after conception. Which is an accurate statement from the nurse about the embryonic stage?

All basic organs are established here

A school nurse is assessing school-age children for developmental milestones. Which students would be a concern for the nurse? Select all that apply.

An 8-year-old student who is not writing with a pencil A 12-year-old student who still has baby teeth An 8-year-old student whose height hasn't changed since preschool An 11-year-old student who is not developing skills for physical games

The parents of a 4-week-old infant bring the child to the health center because they are concerned about the infant's inconsolable crying. The nurse suspects that the infant may be experiencing colic based on which findings? Select all that apply.

Continuous crying lasts for about 3 to 4 hours, occurring almost every evening. Infant draws legs up to abdomen during crying episodes.

The nurse is providing care for an 11-year-old child who has been diagnosed with central auditory processing disorder. Which strategy should the nurse use when teaching this child how to apply a wrist brace?

Demonstration-return demonstration

A nurse is preparing to assess the developmental patterns of a toddler using the Denver Developmental Screening Test (DDST II). When using this tool, which area would the nurse assess? Select all that apply.

Fine motor skills Language Social interaction

A community health nurse is developing a program for young adults about ways to promote health. Which information would the nurse likely include? Select all that apply.

Getting the necessary immunizations as recommended Engaging in safe sexual practices when sexually active Performing self-breast and self-testicular exams monthly Participating in regular physical examinations

Genetic Theory of Aging

Holds that lifespan depends to a great extent on genetic factors.

The nurse is caring for Amy, a 10-year-old, who is admitted for a fractured wrist (suffered during a soccer game) repair. She talks a lot about how well she is doing in school this year and her mother agrees. The nurse is assessing her developmental health and knows that Amy is well on the way to achieving which of the following according to Erik Erikson?

Industry

A school nurse is providing a health education class for a group of high school students. When discussing the issue of safety, which area would the nurse identify as the leading cause of death in adolescents?

Motor vehicle crashes

A nurse is assessing neonates in a hospital nursery. Which neonates are exhibiting expected developmental characteristics? Select all that apply.

Neonate who displays the Moro and stepping reflex Neonate who eliminates urine and stool Neonate who exhibits both an active crying state and a quiet alert state Neonate who inherits a transient immunity from infections from the mother

A school nurse is teaching a sexuality class to 5th- and 6th-grade girls. The nurse talks about secondary sexual characteristics and explains that these are which of the following? Choose all that apply.

Presence of body hair Breast development Facial hair growth in boys Voice changes in boys

A nurse records an Apgar score of 3 for a newborn taken one minute after birth. What would be a priority intervention for this newborn?

Provide immediate life-saving support.

A school nurse is preparing a presentation for the parent-teacher association at the local elementary school. The nurse is focusing on the topic of nutrition in this age group. Which suggestion would be appropriate for the nurse to include? Select all that apply.

Providing foods that are high in calcium Encouraging foods high in vitamin D Avoiding foods that contain empty calories

After assessing a female adolescent, a nurse collects the following data: development of breast tissue, growth spurt in height and weight, appearance of axillary hair, and initiation of menarche. Which stage of sexual development does this data confirm?

Pubescence

The nurse observes a hospitalized preschooler who clings excessively to his mother, sucks the thumb, and uses infantile speech patterns. This child is exhibiting what type of behavior?

Regression

A nurse is working as part of a community health team addressing the issue of child abuse in the community. The team assesses the community for possible risk factors that may be contributing to the increased incidence. Which factor would the team likely identify? Select all that apply.

Substance use by caregivers Poverty Community violence Social isolation of families

An 18 year old with a chronic illness tells the school nurse that he has recently started using marijuana with his friends on weekends. Which of the following should be the nurse's next action?

Teach him about effects of marijuana on his illness and potential complications with marijuana use

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks what the baby can do physically right after birth. Which is an accurate statement about neonatal ability following birth?

The newborn can suck, swallow, sneeze, and yawn

A nurse is preparing a presentation for a group of students who are entering high school in the fall. During the presentation, one of the students asks, "I've heard all sorts of things about puberty. But what exactly is it?" Which information would the nurse incorporate into the response?

The time when a person's ability to reproduce begins

A nurse is working with a nursing student today, whose focus and goal for the day is to assess the developmental stages of his patients. Both are caring for a group of pediatric patients that includes a 2-year-old, a 7-year-old, and a 16-year-old. The nurse and the student discuss Erik Erikson's development theory and the nurse asks the student to put the following tasks and stages in chronological order.

Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Intimacy versus isolation

The nurse is teaching a class to pregnant adolescents and young adults. What does the nurse explain is the most important reason for breastfeeding instead of bottle feeding?

breastfeeding provides protection against infections

The nurse is caring for a young adult client . What developmental task for this age group does the nurse identify as a priority?

Establishing an intimate relationship and family

A nurse is instructing a group of adolescents and young adults about safety. Which of the following topics should be included?

Instructing them about the dangers of bullying and gang involvement Explaining that sports injuries are major causes of fatalities Reviewing the use of protection during sexual activity

During a well-child visit, a mother says, "My child received a meningococcal vaccine at age 11." Which information should the nurse provide to this mother?

A booster shot at age 16 is recommended.

A nurse is participating in a local community health fair. The nurse is providing information about sexually transmitted infections. Which infection would the nurse describe as being the most common?

Chlamydia

During assessment the 5-year-old child says, "I feel good today. I am filled with the Holy Spirit." How does the nurse evaluate this statement?

Concepts such as this are rarely understood by children this age.

The nurse is caring for a female client 15 years of age who is hospitalized with a fractured ankle. Her father tells the nurse that this happened during a gymnastics lesson. He goes on to explain that every six or eight months it seems his daughter is trying something different; right now it is gymnastics. The nurse knows that this behavior fits with which of the following theorist's developmental tasks for adolescents?

Erikson

The nurse is caring for a 19-year-old male client who has suffered multiple fractures related to a motor vehicle accident. His father is at his bedside and, while the client is away for radiology tests, his father talks about his son's injuries and age group in general. The father asks what the major cause of death is in his son's age group. The nurse's best reply is which of the following?`

Injuries related to car accidents

A more thorough medical examination of a 30-month-old is indicated when the nurse observes that the child has difficulty

Kicking a ball

Which of the following topics for the client education of a pregnant woman should the nurse prioritize in an effort to promote healthy fetal development?

Nutrition

A school nurse is reviewing the medical record of a child who was just diagnosed with a learning disability. The record reveals that the child has problems with letters and activities that require hand-eye coordination. The nurse interprets this as which type of learning disability?

Visual perceptual/visual motor deficit

The pregnant young adult states, "I heard all babies develop colic. What causes infant colic?" How does the health care provider explain the causes of infant colic to the client? Select all that apply.

swallowing too much air with feeding laying infant down with propped up bottle allergies to the formula causes abdominal pain