CONTENT AREA DEVELOPMENTAL STAGE
The nurse is providing medication instructions to an older client with chronic heart failure who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy?
Increased risk for digoxin toxicity
The parent of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse would tell the parent that the most appropriate toy for a 3-year-old is which?
A wagon
A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation?
Administering intravenous (IV) fluids
The parents of a 3-year-old are concerned because their child still is insisting on a bottle at naptime and at bedtime. Which is the most appropriate suggestion to the parents?
Allow the bottle if it contains water.
A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?
Allow the client to interact with others in the same (adolescent) age-group.
A 16-year-old client is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?
Allow the client to interact with others in their same age group.
The maternity nurse is providing instructions to a new parent regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the parent to take which measure?
Allow the newborn infant to signal a need.
The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client?
Allowing the client to choose social activities
The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply.
Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset Decline in visual acuity
A parent arrives at a clinic with a toddler and tells the nurse how difficult it is to get the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the parent?
Inform the child of bedtime a few minutes before it is time for bed.
The nurse is preparing to perform a pediatric physical examination. The child refuses to sit on the examining table, screams when the nurse attempts to perform the assessment, and does not make eye contact. What is the most appropriate initial nursing action?
Talk to the parent while ignoring the child.
A client who has been diagnosed with a terminal illness has an advance directive form, needs it to be signed, and asks the nurse to sign it as a witness. What is the nurse's best action?
Ask a nonmedical person, such as a social worker, to witness the form.
A 15-year-old is injured and sustains a fractured jaw. The fractured jaw has been surgically wired, and the primary health care provider (PHCP) has prescribed a full liquid diet. Which nursing action would best promote compliance and provide an adequate nutrient value with the full liquid diet for this teenager?
Ask the teenager for food preferences, and liquefy these foods using a blender.
The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action would the nurse include in the client's plan of care to meet the emotional needs of the client and spouse?
Assess the client's and the spouse's perception of the event.
The nurse in the pediatric unit is admitting a 2½-year-old child. Which stage in Erikson's psychosocial stages of development would the nurse plan care around?
Autonomy versus Shame and Doubt
The nurse at a well-baby clinic is assessing the language and communication developmental milestones of a 4-month-old infant. On the basis of the age of the infant, what would the nurse expect to note as the highest-level developmental milestone?
Babbling sounds
The nurse at a well-baby clinic is providing nutrition instructions to the parent of a 1-month-old infant. What instruction would the nurse give to the parent?
Breast milk or formula is the main food.
The nurse educator is preparing to conduct a teaching session about school-age children regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information would the nurse include in the session? Select all that apply.
In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned. Moral development progresses in relationship to cognitive development. A person's ability to make moral judgments develops over a period of time. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior.
Which interventions would the nurse take for a deceased client whose eyes will be donated? Select all that apply.
Close the client's eyes. Elevate the head of the bed. Place wet saline gauze pads and a cool pack on the eyes.
The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?
Crusting
The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply.
Decline in visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset
The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?
Document the finding.
The nurse is monitoring a 3-month-old infant with hydrocephalus for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?
Document the finding.
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would be implemented to alleviate the child's fears?
Encourage the child's parents to stay with the child.
The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse would implement which intervention?
Encourage the client to maintain maximum self-control.
The nurse is caring for a terminally ill client. The nurse has developed a close relationship with the family of the client. Which interventions would the nurse plan to employ? Select all that apply.
Encouraging family discussion of feelings Accepting the family's expressions of anger Allowing spiritual practices identified by the family Preserving the family's sense of self-direction and control
The nurse is caring for a client with terminal lung cancer who is close to death. On reviewing the plan of care, the nurse determines that which intervention is the priority?
Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.
The nurse is preparing to describe Piaget's cognitive developmental theory to pediatric nursing staff. The nurse would plan to tell the staff that which child behavior is characteristic of the formal operations stage?
The child's basic abilities to think abstractly and problem-solve are similar to an adult's.
The nurse notes that an older client with dementia is unable to care for self to bathe and perform other activities of daily living (ADL). Which is an appropriate goal for this client?
The client will function at the highest level of independence possible.
The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply.
The nurse encourages the client and family to identify and discuss feelings openly. The nurse assists the client and family in carrying out spiritually meaningful practices. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.
The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What would the nurse tell the AP about older clients with hearing loss?
They respond to low-pitched tones.
The nurse is caring for a dehydrated client who is terminally ill. When caring for this client, the nurse would take which action?
Use moist cloths and swabs for mouth comfort.
An older client is admitted to the hospital with a diagnosis of malnutrition. Other than cognitive status, what other factors can increase the risk of malnutrition and dehydration? Select all that apply.
Physical fatigue Limited mobility Sensory decreases Inadequate dental care
The parents of a toddler inform the nurse that their child has frequent temper tantrums. The nurse would instruct the parents to implement which measure to deal with the temper tantrums?
Ignore the behavior.
The nurse is providing medication instructions to an older client with atrial fibrillation who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy?
Increased risk for digoxin toxicity
The hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's spouse states, "I don't understand why the morphine is necessary. My spouse has no pain." What would the nurse include in the explanation of the purpose of the morphine?
It helps to reduce anxiety and oxygen consumption.
The nurse is caring for a 14-year-old child who is hospitalized and has been placed in traction using Crutchfield tongs. The child is having difficulty adjusting to the prolonged hospital confinement. Which nursing action would be appropriate to meet the child's needs?
Let the child wear own clothing when friends visit.
The pediatric nurse is caring for a hospitalized toddler. What does the nurse determine is the most appropriate play activity for the toddler?
Playing with a push-pull toy
The nurse is assigned to care for a hospitalized toddler. The nurse plans care, knowing that what would be the highest priority?
Protecting the toddler from injury
The community health nurse is providing an educational session to a group of community members regarding the issue of organ donation. A member of the group asks the nurse, "How old does someone have to be to provide consent for organ donation?" Which response would the nurse make?
"A donor must be 18 years of age or older to provide consent."
The parents of a 16-year-old tell the nurse that they are concerned because their child sleeps about 9 hours every night and until noon every weekend. Which nursing response is most appropriate?
"Adolescents need that amount of sleep every night."
The parent of an 8-year-old child tells the clinic nurse of a concern that the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse would plan to make which response?
"At this age, children are developing their own personalities."
The parent of an 8-year-old child tells the clinic nurse that they are concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse would make which response?
"At this age, the child is developing his own personality."
The clinic nurse provides information to the parents of a toddler regarding toilet training. Which statement by one of the parents indicate a need for further information regarding toilet training?
"Bladder control usually is achieved before bowel control."
A terminally ill client asks the nurse about hospice care, and the nurse educates the client about the hospice program. Which statement by the client indicates that teaching has been effective?
"Clients have a prognosis of 6 months or less to live."
The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?
"I drink hot chocolate before bedtime."
The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse would expect which statement that is aligned with the psychosocial expectations of this age?
"I know it hurts to die."
A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate?
"I will contact the medical examiner regarding your request."
A parent of a 4-year-old expresses concern because their hospitalized child has begun thumb sucking. The parent states that this behavior began 2 days after hospital admission. Which response by the nurse is appropriate?
"It is best to ignore the behavior."
The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional instruction when the caregiver makes which statement?
"Palliative care interventions hasten death."
The clinic nurse has provided instructions about dental care for toddlers to the mother of a 2-year-old child. Which statement, if made by the parent, indicates a need for further instruction?
"Proper dental care is not necessary for a toddler until the permanent teeth erupt."
While the nurse is caring for a client with severe cardiac disease, the client states, "If anything would happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which nursing action is appropriate?
Notify the primary health care provider (PHCP) of the client's request.
The nurse is caring for a client who is dying. The nurse recognizes that which intervention is likely to facilitate therapeutic communication between the dying client and the client's family? Select all that apply.
The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. The nurse is supportive and nonjudgmental of the client's or family's verbalized concerns and feelings. The nurse encourages the client and family to identify and discuss feelings openly. The nurse assists the client and family in carrying out spiritually meaningful practices.
A nursing student is preparing to present a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student would plan to explain to the group that which characteristic relates to the anal stage?
This stage is associated with toilet training.
A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. While preparing the nursing care plan for this child, which factor would the nurse take into consideration?
This surgery is taking place at a time when fears of separation are great.
The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply.
Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know that they will not be abandoned by the nurse. Encourage expression of feelings, concerns, and fears.
The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death following a severe head injury. Which finding indicates to the nurse that the standard for ongoing care has been maintained?
Urine output 100 mL/hr
Which would be the highest expected growth and development occurrences at 10 months of age for an infant who has had appropriate growth assessed at each well-child visit? Select all that apply.
Would be able to say "mama" and "dada" Will pull up and stand for several seconds holding on to furniture Will be able to pick up small pieces of food when placed in a high chair
The parent of 6-year-old twins says to the nurse, "My parental-in-law doesn't think our children need to come to the funeral service for their grandparent. What do you advise?" The nurse would respond by making which statement?
"What do you and your spouse believe is the right thing for your children?"
The spouse of a terminally ill client steps out of the client's room in tears. The spouse tells the nurse, "I don't know what I'm going to do when my spouse is gone!" What is the nurse's best response?
"This must be very hard for you."
During morning rounds the nurse comes into the room of a client who is unresponsive and near death. Two assistive personnel (APs) are bathing the client, and their conversation centers on their plans for a weekend party. How would the nurse best intervene?
Speak to the client and touch touch the client's hand, saying, "Hello, we will be finished with your bath shortly."
The visiting nurse observes that an older client is confined by their child to the room. When the nurse suggests that the client walk to the den and join the family, the client says, "I'm in everyone's way; my child needs me to stay here." Which is the most important action for the nurse to take?
Suggest appropriate resources to the client and child, such as respite care and a senior citizens center.
A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home?
"We will be sure not to leave hot liquids unattended."
An infant is being seen in the pediatrician's office for a 2-month-old well-child visit. The nurse encourages the parent to allow the infant to suck on a pacifier during a routine immunization. The nurse explains to the parent that the child is at which stage of Piaget's cognitive development?
Sensorimotor development
The nurse is caring for an older client in a long-term care facility. Which action does the nurse plan that will contribute to encouraging autonomy in the client?
Allowing the client to choose social activities
Which interventions are appropriate for the care of an infant? Select all that apply.
Provide swaddling. Hang mobiles with black and white contrast designs. Caress the infant while bathing or during diaper changes.
The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse would plan to tell the parent that which factor motivates good and bad actions for the child at the preconventional level?
Punishment and reward
The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action would the nurse take?
Report the observation to the pediatrician.
The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take?
Report the observation to the pediatrician.
The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse would implement which interventions? Select all that apply.
Retain ritualism. Avoid significant changes in lifestyle. Maintain sensitivity toward the parents. Encourage the parents to be near the child. Encourage as normal an environment as possible.
