Final

A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL ________ 100 gtt/min

100 gtt/min

A nurse in the pediatric clinic is reviewing the chart of a 1-year-old infant before the examination. The infant's birthweight was 7lb 8oz. What weight should the nurse expect the infant to be at 1 year of age? Record your answer rounding to one decimal place. _______ lb

22.5 lb rational: 7.5 lb x 3 = 22.5 lb

A nurse is preparing to administer acetaminophen 10/mg/kg PO to a preschool child for fever. The child weighs 22 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ________ mL

3.1 mL rational: Desired Over Have STEP 1: What is the unit of measurement the nurse should calculate? mL STEP 2: What is the dose the nurse should administer? Dose to administer= Desired 100 mg STEP 3: What is the dose available? Dose available = Have 160mg STEP 4: Should the nurse convert the units of measurement? No STEP 5: What is the quantity of the dose available? 5 mL STEP 6: Set up an equation and solve for X. Desired x Quantity/Have = X 100 mg x 5 mL/160 mg = X mL 3.125 mL = X STEP 7: Round if necessary. 3.125 = 3.1 STEP 8: Reassess to determine whether the amount to give makes sense. If there are 160 mg/5 mL and the amount prescribed is 100 mg, it makes sense to administer 3.1 mL. The nurse should administer acetaminophen liquid 3.1 mL.

A nurse in the family planning clinic reviews the health history of a sexually active 16 yo girl whose chief concern is a this, burning vaginal discharge accompanied by low abdominal pain. After her exam, the girl is informed that she may have a, STI that requires treatment. The adolescent is concerned that her parents will discover that she is sexually active. She asks the nurse whether her parents will be contacted. The nurse explains that her parents will: a Not be contacted, because treatment at the clinic is confidential b. Need to be informed to sign a consent form for testing and treatment c. Be notified when the insurance company is billed for testing and treatment d. Will not be told if the adolescent promises to have her sexual contacts tested

a Not be contacted, because treatment at the clinic is confidential rational: federal law allows family planning clinics to maintain minors' confidentiality, although individuals states may have different regulations. There is a concern that teenagers will not seek or continue treatment if they fear disclosure.

A nurse is caring for a 4 yo child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make? a. "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better." b. "I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me." c. "Why is she wetting the bed in the hospital? She must wet the bed at home." d. "I will discuss your child's loss of bladder control with the provider."

a. "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better." rational: A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. It is appropriate to reassure he parents that regression is an expected behavior in children who are hospitalized, and that they regain bladder control when their health improves.

A nurse is collecting data from a 10 yo child during a well-child visit. Which of the following statements by the child indicates he is meeting the psychosocial development expectations of a school-age child? a. "I really want to do well in school." b. "I like to collect rocks." c. "My parents set rules that I need to follow." d. "I can do simple math problems in my head."

a. "I really want to do well in school." rational: Erikson's stage of psychosocial development for a 10 yo client is industry vs inferiority. Children at this age want to perform well in school to develop a sense of accomplishment

The nurse provides nutritional counseling to the parents of a 6 mo old formula-fed infant who will begin eating solid foods. Which statement by a parent indicates understanding of the nurse's advice? a. "I'll keep give him formula instead of regular cow's milk." b. "I'll buy plenty of pureed spinach so she gets enough iron." c. "Using a natural sweetener like honey is better than using table sugar." d. "Baby food is sterilized, so it's better to feed directly from the jar than from a bowl."

a. "I'll keep give him formula instead of regular cow's milk." rational: infants should receive formula or breast milk for a full year; cow's milk should not be introduced until 1 year of age.

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory? a. "Individuals move through all six stages in a sequential fashion." b. "Moral development progresses in relation to cognitive development." c. "A person's ability to make moral judgments develops over a period of time." d. "It provides a framework for understanding how individuals determine a moral code to guide his or her behavior."

a. "Individuals move through all six stages in a sequential fashion." rational: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5-6 as part of their development of personal morality.

The nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is which? a. "The child has the ability to think abstractly." b. "The child develops logical thought patterns." c. "The child begins to understand the environment." d. "The child has difficulty separating fantasy from reality."

a. "The child has the ability to think abstractly." rational: in the formal operations stage, the child has the ability to think abstractly and solve problems.

The parents of a 4 yo child tell the nurse that they are concerned because the child has be masturbating. Which is the appropriate response by the nurse? a. "This is a normal behavior at this age." b. "Children usually begin this behavior at the age of 8 years." c. "This is not normal behavior. The child should be brought to the mental health clinic. d. "The child is very young to begin this behavior and should be brought to the mental health clinic."

a. "This is a normal behavior at this age." Rational: According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3-6yo. At this time, the child devotes much energy to examining his or her genitalia, masterbating, and expressing interest in sexual concerns.

A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is the best response by the nurse? a. Baby cereals b. Soft-boiled eggs c. Fruits and puddings d. Meats and vegetables

a. Baby cereals rational: the first solid food added to the infant's diet should be easily digestible; fortified cereals are easy to digest and a rich source of iron.

Which theory explains psychosexual development through infancy to adolescence? a. Freud's theory b. Piaget's theory c. Erikson's theory d. Kohlberg's theory

a. Freud's theory rational: Psychosexual development through the five development stages is explained by Freud's theory

A 10 yo child has been working on earning all the scouting badges. Which of Erickon's stages of psychosocial development is this child achieving? a. Identity b. Industry c. Intimacy d. Initiative

a. Identity rational: The school-aged child is working on industry vs inferiority. A sense of accomplishment is an important part of this stage

A toddler has frequent temper tantrums. The parents ask a nurse how to limit this acting-out behavior. What should the nurse recommend? a. Ignore the tantrum whenever possible. b. Restrain the child whenever a tantrum begins. c. Move the child to a quiet area as soon as a tantrum begins. d. Visit the clinic to request medication to control the tantrum.

a. Ignore the tantrum whenever possible. rational: ignoring the temper tantrum as long as the child is not causing self-harm avoids reinforcement of the behavior

Which development stage is Jean Piaget's fist stage of cognitive development? a. Sensorimotor b. Preoperational c. Formal operational d. Concrete operational

a. Sensorimotor rational: Piaget's first stage of cognitive development is sensorimotor stage (birth to 2 years)

a 6-week-old infant grasps a rattle placed in the hand. The mother is impressed with this skill. What should the nurse teach the mother about this behavior? a. This is the palmar grasp reflex and is expected at this age. b. This is the pincer grasp, which disappears within several months. c. Grasping is a voluntary behavior usually observed in older infants. d. Grasping is an atypical behavior and further evaluation is required.

a. This is the palmar grasp reflex and is expected at this age. rational: the palmer grasp reflex is expected at 6 weeks of age, begins to fade at 2 months, and disappears by 4 months.

The RN is teaching the mother of an infant about the prevention of sudden infant death syndrome (SIDS). Which statement by the mother indicates effective learning? a. "I will sleep in the bed with my baby." b. "I will position my baby on the back while sleeping." c. "I will use warm blankets and sheets to cover my baby." d. "I will put my baby to sleep on soft bedding with pillows."

b. "I will position my baby on the back while sleeping." rational: sleeping on the stomach may cause upper airway obstruction and increase the risk of SIDS. Therefore, infants should placed on their backs to decrease this risk.

The nursing student is preparing a conference on Freud's psychosexual stages of development, specially the anal stage. Which appropriately relates to this stage? a. Gratification of self b. Beginning of toilet training c. Tapering off of conscious biological and sexual urges d. Association with pleasurable and conflicting feelings about the genital organs

b. Beginning of toilet training rational: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces

According to Kubler-Ross, during which stage of grieving are individuals with serous health problems most likely to seek other medical opinions? a. Anger b. Denial c. Bargaining d. Depression

b. Denial rational: denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions

An 8 yo girl boasts to the nurse that she got a gold star every day last week for doing all her daily chores. What is the child's development stage according to Erikson? a. Initiative vs. guilt b. Industry vs. inferiority c. Identity vs. role confusion d. Autonomy vs. shame and doubt

b. Industry vs. inferiority rational: According to Erikson's developmental theory, children who are 6-12 yo are in the stage of industry vs inferiority. In this stage, they are interested in performing tasks to attain achievement.

A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actins should the nurse take first? a. Report the suspected abuse to the authorities. b. Obtain a detailed history. c. Request a social services referral. d. Tell the child what will happen to her when the abuse is reported.

b. Obtain a detailed history. rational: The nurse should first obtain a history in order to determine possible causes of the bruises. While collecting additional data, the nurse should observe the parent and child for other indicators of abuse.

In all states of the US, what is the professional nurse's legal responsibility regarding child abuse? a. Honor the request of the parents not to report the suspected abuse. b. Report any suspected abuse to local law enforcement authorities. c. Return the child to the legal parent even if he or she is suspected of abuse d. Provide the parents with a copy of the child's medical record.

b. Report any suspected abuse to local law enforcement authorities.

What concept of death should a nurse expect a 4 yo to have? a. Cessation of life b. Reversible separation c. Only affects old people d. Force takes one away from family

b. Reversible separation rational: Preschoolers view death as a separation; they believe that the deceased will return to life. This is part of their fantasy world. Preschoolers view death as a separation, or possibly a kind of sleep, and expect the deceased to return or wake up.

According to Piaget, what behavior should the nurse expect to find in a 7yo child? a. The child compares religious beliefs with science. b. The child classifies and sorts facts to solve problems. c. The child uses abstract symbols and draws conclusions. d. The child views objects in terms of their relationships or their use to them.

b. The child classifies and sorts facts to solve problems. rational: a 7 yo child is usually in the concrete operation stage of Piaget's development theory, and should have the ability to classify and sort problems.

During a well-baby clinic visit, the nurse finds that a 1 yo infant says "ma" and "pa". The infant does not say anything else and uses gestures to communicate. What should the nurse infer from this finding? a. The infant needs to spend more time with peers. b. The infant exhibits normal language development. c. The infant needs a consultation with the pediatrician d. The infant may have impaired cognitive development.

b. The infant exhibits normal language development. rational: Infants usually very few words to convey their needs, and rely mostly on gestures. Therefore, the infant has normal language development.

What is a characteristic of play among toddlers? a. Toddlers play with each other. b. Toddlers play beside each other. c. Toddlers play in organized groups. d. Toddlers play by themselves.

b. Toddlers play beside each other. rational: Toddlers tend to play beside each other, not with each other. This type of play is called parallel play

What is a characteristic of play among toddlers? a. Toddlers play with each other. b. Toddlers play beside each other. c. Toddlers play in organized groups. d. Toddlers play by themselves.

b. Toddlers play beside each other. rational: Toddlers tend to play beside each other, not with each other. This type of play is called parallel play.

Which is the cognitive development stage of adolescents according to Piaget? a. sensorimotor stage b. formal operations stage c. preoperational stage d. concrete operational stage

b. formal operations stage rational: according to Piaget, the cognitive development stage of adolescents is called the formal operations stage. this stage involves the logical use of symbols related to concept that are abstract.

In which stage of development can a child identify with the parent of the same sex, according to Freud's theory? a. oral b. phallic c. genital d. latency

b. phallic rational: the development of sexual identity is the major developmental task in the phallic stage. Therefore, ID with the parent of the same sex takes place in this stage

A nurse is talking with a 13 yo female client who is having her annual health-screening visit. Which of the following comments by the clients should concern the nurse? a. "My parents treat me like a baby sometimes." b. "I start taking ibuprofen a few days before my period starts." c. "None of the kids at my school like me, and I don't like them either." d. "There's a pimple on my face, and I worry that everyone will notice it."

c. "None of the kids at my school like me, and I don't like them either." rational: this statement should concern the nurse, as developing a peer group is critical to adolescent development and self-esteem. the nurse should explore this comment in greater depth.

The parents of a 3.5 yo tell the nurse that their child has become a "picky eater" and has not gained much weight. How should the nurse respond? a. "This is not expected; your child may be sick." b. "This is a fast growth period; you need to give your child vitamins." c. "Your child is growing slower; preschoolers don't have large appetites." d. "Preschoolers enjoy gifts; offer a reward when your child eats an entire meal."

c. "Your child is growing slower; preschoolers don't have large appetites." rational: Growth slows after the first year of life, and preschoolers and toddlers eat less

While a 3-month-old infant is at the well-baby clinic for a checkup, the parents express concern that their baby still has a soft spot on the top of the head. The nurse informs the parents that their infant's anterior fontanel will close around: a. 6 to 8 months of age b. 9 to 12 months of age c. 12 to 18 months of age d. 19 to 36 months of age

c. 12 to 18 months of age rational: according to the standards of growth and development, the anterior fontanel closes between 12 and 18 months of age

During a clinic visit a 4 yo girl suddenly yells, "Don't sit on Erin!" The parent whispers that Erin is an imaginary friend. What is the nurse's best action? a. Referring the parents to classes on parenting b. Providing special instructions for appropriate discipline c. Avoiding sitting where the child says her imaginary friend is located d. Making a referral to a child psychologist regarding the imaginary friend

c. Avoiding sitting where the child says her imaginary friend is located rational: Imaginary friends are typical of children of this age. Avoiding injury to the child's imaginary friend will result in less stress for the child. There is no evidence that the parents are having difficulty with child-rearing.

Considering Erikson's developmental theories, a 21 yo male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with: a. Mastering his environment b. Identifying with the male role c. Developing meaningful relationships d. Differentiating himself from the environment

c. Developing meaningful relationships rational: developing meaningful relationships is the young-adult task associated with intimacy versus isolation

A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning? a. Autonomy vs. shame and doubt b. Initiative vs. guilt c. Industry vs. inferiority d. Identity vs. role confusion

c. Industry vs. inferiority rational: school-age children, according to Erikson's developmental stages of industry vs. inferiority, engage in tasks and activities that help them develop competence and perseverance.

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures to: a. Restore the client's health b. Promote the client's recovery c. Relieve the client's discomfort d. Support the client's significant others

c. Relieve the client's discomfort rational: palliative measures are aimed at relieving discomfort without curing the problem

A girl comes to the physician's office for her 14 yo check up. What is the most important anticipatory guidance that can be offered to the client? a. Abstinence b. Healthy Diet c. Ways to prevent accidents d. Correct handwashing technique

c. Ways to prevent accidents rational: The biggest health risk for adolescents is accidents (the number one cause)

A nurse is reinforcing teaching with the parents of adolescent about expected development. Which of the following developmental tasks should the nurse instruct the parents to expect the adolescent to achieve? a. trust b. initiative c. identity d. autonomy

c. identity rational: the adolescent should achieve the developmental task of establishing an identity

A nurse is teaching a mother about the immunization schedule for her baby. Between which months of age should the measles vaccine be given? a. 2 and 5 b. 6 and 8 c. 9 and 11 d. 12 and 15

d. 12 and 15 rational: between 12-15 months is the optimal age because maternal antibodies to measles are no longer present to block the formation of the child's own antibodies

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kubler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? a. Anger b. Denial c. Bargaining d. Acceptance

d. Acceptance rational: communication and interventions during the acceptance stage are mainly nonverbal (ex. holding the client's hand). the nurse should be quiet but available.

When does the Babinski reflex disappear? a. By 6 months b. By 4 months c. By 3 months d. After 12 months

d. After 12 months rational: the Babinski reflex disappears after 1 year or 12 months

Which stage of development is observed in a 9-year-old child according to Jean Piaget's cognitive development theory? a. Sensorimotor b. Preoperational c. Formal operational d. Concrete operational

d. Concrete operational rational: the concrete operational stage is observed in children between 7-11 years of age. In this stage, the child can perform mental operations, and the thought process is more coherent

What is the cognitive development stage of school-age children? a. Sensorimotor b. Preoperational c. Formal operations d. Concrete operations

d. Concrete operations rational: School-age children are considered to be in the concrete operations stage of cognitive development.

While playing, a child takes a few pebbles and places them in order from smallest to largest. Which stage of cognitive development does the child behavior demonstrate? a. Sensorimotor b. Preoperational c. Formal operations d. Concrete operations

d. Concrete operations rational: during the stage of concrete operations, the child's thought becomes more logical and coherent. The child in this stage is able to classify, sort, order, and organize facts about the world to use in problem-solving. Therefore, the child placing the pebbles in order of smallest to largest indicates that the child is in the stage of concrete operations.

A middle-aged adults contributes to future generations through parenthood, teaching, and community involvement. To which stage of Erikson's theory does this relate? a. Ego integrity versus despair b. Intimacy versus isolation c. Identity versus role confusion d. Generativity versus stagnation

d. Generativity versus stagnation rational: In the generativity versus stagnation stage, the adult focuses on supporting future generations. Middle-aged adults achieve success in this stage by contributing to future generations through parenthood, teaching, and community involvement.

A nurse is caring for 3 yo children. At what stage of cognitive thought does the nurse expect them to be? a. Intuitive b. Abstract c. Concrete d. Preconceptional

d. Preconceptional rational: According to Piaget, at approximately 2 years of age the toddler enters the preconceptional phase of cognitive thought, which lasts, at most, until about 4 yo; the preconceptional phase is a subdivision of the preoperational stage, which lasts from 2-7 yo.

Which toddler behavior reflects animism? a. Toddlers love to keep pets. b. Toddlers are fearful of cats and dogs. c. Toddlers like to watch animal cartoons. d. Toddlers attribute lifelike qualities to inanimate objects.

d. Toddlers attribute lifelike qualities to inanimate objects. rational: This behavior is call animism. They may talk to toys or scold the floor

The mother of a 5 mo infant tells the nurse that she has started to feed her baby fortified cereal mixed with formula. She asks in which order she should introduce new foods. What foods should be selected first? a. Meats and fish b. Eggs and cheeses c. Citrus fruits and bread d. Vegetables and noncitrus fruits

d. Vegetables and noncitrus fruits rational: Generally it is recommended that veggies and noncitrus fruits be introduced after cereals because they are easily digested

A nurse has accepted a position on a pediatric unit and is learning more about psychosocial development. Identify the order of Erikson's stages of psychosocial development from birth through 18 years of (Move steps into order of performance a. Autonomy vs. shame and doubt b. Industry vs. inferiority c. Identity vs. role confusion d. Initiative vs. guilt e. Trust vs. mistrust

e. Trust vs. mistrust a. Autonomy vs. shame and doubt d. Initiative vs. guilt b. Industry vs. inferiority c. Identity vs. role confusion

A nurse is reinforcing teaching about health promotion with an adolescent. The nurse includes which of the following as the leading cause of death among this age group? a. ​Suicide b. ​Homicide ​c. Injuries ​d. Cancer

​c. Injuries rational: unintentional injuries are the leading cause of death among adolescents