Growth, Development, and Stages of Life

The community health nurse is providing an educational session to a group of community members at a local high school 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 should the nurse make?

"A donor must be 18 years of age or older to provide consent."

The mother of a 16-year-old tells a nurse that she is concerned because her child sleeps about 8 hours every night and until noontime every weekend. Which nursing response is most appropriate?

"Adolescents need that amount of sleep every night."

The nurse is caring for a terminally ill client who is unresponsive to verbal stimuli. The client's spouse asks if her husband can still hear her. Which is the best response by the nurse?

"Assume that your husband can still hear you."

The mother of an 8-year-old child tells the clinic nurse that she is 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 should make which response?

"At this age, the child is developing his own personality."

The clinic nurse provides information to the mother of a toddler regarding toilet training. Which statement by the mother indicates a need for further information regarding toilet training?

"Bladder control usually is achieved before bowel control." Rationale: Bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness for toilet training. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between the ages of 18 and 24 months.

The nurse in the well-baby clinic has provided instructions regarding dental care to the mother of a 10-month-old child. Which statement by the mother indicates a need for further instruction?

"I can coat a pacifier with honey during the day so long as I do not give my child a bottle at nap or bedtime."

A client brought to the emergency department is dead on arrival (DOA). The emergency department health care provider examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response by the nurse is most appropriate?

"I will contact the medical examiner regarding your request."

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider (HCP) that the client had terminal cancer. The emergency department HCP examines the client and asks the nurse to contact the medical examiner regarding an autopsy. Family members of the client tell the nurse that they do not want an autopsy performed. Which response to the family is appropriate?

"I will contact the medical examiner regarding your request."

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests no autopsy be performed. Which response to the family is most appropriate?

"I will contact the medical examiner regarding your request."

Which statement indicates the "law and order orientation" found in level two of Kohlberg's theory of moral development?

"If I skip down the hall, will the teacher be mad at me?" RATIONALE: In the law and order orientation of Kohlberg's theory, the child has more concern with society as a whole and emphasis is on obeying laws to maintain social order. The child wants to be considered "good" by persons whose opinions matter to them. Option A is the only option that reflects these criteria. Option B, C, and D are unrelated to the law and order orientation.

A mother of a 4-year-old expresses concern because her hospitalized child has begun thumb sucking. The mother states that this behavior began 2 days after hospital admission. Which response by the nurse is most appropriate?

"It is best to ignore the behavior." Rationale: In the hospitalized preschooler, the best option is to accept regression if it occurs. Regression is most often a result of the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home. When regression does occur, the best approach is to ignore it while praising existing patterns of appropriate behavior. Calling the health care provider is not necessary. Options 2 and 4 are inappropriate.

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 nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The correct response by the nursing student is which statement?

"The child has the ability to think abstractly."

The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. Using Freud's psychosexual stages of development, the nurse should make which response?

"This is a normal behavior at this age."

The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response?

"This must be very hard for you."

The 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."

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse most appropriately responds by making which statement?

"What do you and your husband believe is the right thing for your children?"

The nurse is instructing the caregiver of a child about reprimanding the child. The nurse recognizes that additional teaching is needed if the caregiver makes which statement to the child?

"You need to stop hitting your sister." Rationale: When reprimanding children, the person reprimanding should focus only on the misbehavior, not on the child. "I" messages rather than "you" messages should be used to express personal feelings without accusation. An "I" message attacks the behavior, not the child.

The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply.

- Loss of consciousness -Loss of bowel control -Loss of bladder control -Decreased blood pressure -Decreased tactile sensation

Which interventions should 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 preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

-Encourage expression of feelings, concerns, and fears. -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.

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply.

-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. -In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

The nurse is caring for a 4-year-old child. When experiencing pain, the nurse anticipates which about the child? Select all that apply.

-Views pain as a punishment -Blames someone else for the pain -Believes pain will disappear magically

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at nap time. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1.Provide swaddling. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes.

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

A 16-year-old 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 child to interact with others in his or her same age group.

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure?

Allow the newborn infant to signal a need.

The mother of a 5-year-old child tells the nurse that the child scolds the floor or a table if she hurts herself on the object. According to Piaget's Theory of Cognitive Development, what term or phrase best describes this behavior?

Animism

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life?

Anxiety

A client has an advance directive form and 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 client, such as a social worker, to witness the form.

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action?

Ask the client who might be available to serve as a witness.

A 15-year-old is injured and sustains a fractured jaw. The fractured jaw has been surgically wired, and the health care provider 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 blenderize these foods into liquids.

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should 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. **ALWAYS asses the situation before reacting

The nurse in the pediatric unit is admitting a 2½-year-old child. The nurse plans care, knowing that the child is in which stage of Erikson's psychosocial stages of development?

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 should the nurse expect to note as the highest-level developmental milestone?

Babbling sounds

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?

Crayons and a coloring book

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.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should 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 should implement which intervention?

Encourage the client to maintain maximum self-control.

The nurse is caring for a dying client who adheres to Judaism. The nurse demonstrates cultural sensitivity when caring for this client by taking which action?

Encouraging a rabbi to sit with the client

A nurse assesses an older client. The nurse recognizes which as an abnormal assessment finding in this client?

Evidence of abdominal ascites

The nurse is developing a plan of care for a 4-year-old child scheduled for a renal biopsy. What developmental characteristic of this child should the nurse consider?

Fears of mutilation may be present in the child.

A mother tells the nurse in a pediatrician's office that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse explores which suggestion with the mother to decrease the children's sense of isolation and fear?

Find community after-school programs or activities.

The nurse is working with older clients in a long-term care facility. Which activity performed by the nurse fosters reminiscence among these clients?

Having storytelling hours

The mother of a toddler informs the nurse that her child has frequent temper tantrums. The nurse should instruct the mother to implement which measure to deal with the temper tantrums?

Ignore the behavior.

The nurse is caring for a Hindu client who has just died. The nurse demonstrates cultural awareness when providing postmortem care by taking which action?

Instructing the unlicensed assistive personnel (UAP) to not wash the body

A 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 wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should 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 terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position?

Lateral

The nurse is caring for a 14-year-old girl 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 most appropriate to meet the child's needs?

Let the child wear her own clothing when friends visit.

The nurse is caring for a client with terminal 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.

While a nurse is caring for a client with severe cardiac disease, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which nursing action is most appropriate?

Notify the health care provider of the client's request.

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which best describes Cheyne-Stokes respirations?

Periods of apnea followed by deep rapid breathing

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

With which age group should the nurse use "magical thinking" as a developmental strategy when administering medications?

Preschool

The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which most appropriate intervention?

Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization

An infant is being seen in the pediatrician's office for a 2-month-old well-child visit. The nurse encourages the mother to allow the infant to suck on a pacifier during a routine immunization. The nurse explains to the mother that the child is in which stage of Piaget's cognitive development?

Sensorimotor development

A terminally ill client asks the nurse about hospice. The nurse plans a response, knowing that a qualification for hospice care is that the health care provider must certify that the client has how much longer to live?

Six months or less

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.

The nurse at a well-baby clinic is providing nutrition instructions to the mother of a 1-month-old infant. What instruction should the nurse give to the mother?

That breast milk or formula is the main food

The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. Which is the correct interpretation of the behavior?

The child exhibits detachment. Rationale: The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In detachment, when the parents return, the child becomes more interested in the environment and new persons (seemingly unaware of the lost parents), friendly with the staff, and interested in developing superficial relationships. In the stage of protest, the child may cry, scream, and search for a parent. In the stage of despair, the child may be withdrawn and uninterested in the environment. That the child is withdrawn, self-centered, or that the child has adjusted to the hospital setting are incorrect interpretations of the child's behavior.

A 10-year-old child has been diagnosed with type 1 diabetes mellitus, and the nurse prepares to educate the family. The child is very active socially and often is away from the parents. Which is the best focus of the nurse's teaching for this client?

The child is taught how to monitor insulin requirements and how to self-administer the insulin.

The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and family?

The nurse makes decisions for the client and family to relieve them of unnecessary demands.

The nursing instructor asks a nursing student to present a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student plans the conference, knowing that which characteristic relates to this stage of development?

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 should the nurse take into consideration?

This surgery is taking place at a time when fears of separation are great.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff?

Two thirds of the distance between the antecubital fossa and the shoulder Rationale: The size of the blood pressure cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should cover two thirds of the distance between the antecubital fossa and the shoulder.

The nurse is caring for a dehydrated client who is terminally ill. When caring for this client the nurse should take which action?

Use moist cloths and swabs for mouth comfort.

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?

Uses a cup to drink

The clinic nurse assesses the communication patterns of a 5-month-old infant. Which assessment finding should lead the nurse to determine that the infant is demonstrating the highest level of developmental achievement expected?

Uses monosyllabic babbling

The nurse who volunteers at a senior citizens' center is planning activities for the members who attend the center. Which activity would best promote health and maintenance for these senior citizens?

Walking three to five times a week for 30 minutes