NCLEX PN Infancy to Adolescence Review
which interventions are appropriate for the care of an infant? select all that apply provide swaddling talk in a loud voice provide the infant with a bottle of juice at naptime hang mobiles with black-and-white contrast designs caress the infant while bathing or during diaper changes allow the infant to cry for at least 10 minutes before responding
provide swaddling // hang mobiles with black-and-white contrast designs // caress the infant while bathing or during diaper changes rationale holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. to provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. additional interventions include playing a music box, radio, or television or having a ticking clock or metronome nearby. hanging a bright, shiny object within 20 to 25 cm of the infant's face in the midline and hanging mobiles with contrasting colors provide visual stimulation. crying is an infants way of communicating; therefore, the nurse would respond to the infants crying. the mother is taught to do so also. an infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda or sweetened water because of the risk of nursing (bottle-mouth) caries
the parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. which is the most appropriate nursing response? a) adolescents love to sleep late in the morning b) the child shouldn't be staying up so late at night c) if the child eats properly, that shouldn't be happening d) the child should have a blood test to check for anemia.
a) adolescents love to sleep late in the morning rationale the sleep patterns of the adolescent vary some according to individual needs. however, in general, adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school. the other options are incorrect
the nurse is providing instructions to a new parent regarding the psychosocial development of the infant. using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents? a) allow the infant to signal a need b) anticipate all of the needs of the infant c) attend to the crying infant immediately d) avoid the infant during the first 10 minutes of crying
a) allow the infant to signal a need rationale according to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. if an infant is not allowed to signal a need, he or she will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others. therefore, the remaining options are incorrect
a mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. according to Piaget's theory of cognitive development, which behavior is this known as? a) animism b) egocentric speech c) object permanence d) global organization
a) animism rationale animism means that all inanimate objects are given living meaning. object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. egocentric speech occurs when the child talks just for fun and cannot see another's point of view. global organization means that if any part of an object or situation changes, the whole thing has changed. the second and last option occur during the preoperational stage
the nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. which is the most appropriate activity for this child? a) blocks b) a puzzle c) a music video d) large picture books
b) a puzzle rationale in the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games. puzzles are also appropriate and aid with fine motor development. blocks are most appropriate for the toddler. a music video is most appropriate for the adolescent. large picture books are most appropriate for the infant.
when caring for a 3-year-old child, the nurse should provide which toy for the child? a) a puzzle b) a wagon c) a golf set d) a farm set
b) a wagon rationale toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. toddlers need supervision at all times. push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. a farm set and a golf set may contain items that the child could swallow.
the nurse provides instructions to a parent of a toddler experiencing physiological anorexia. the nurse determines the need for further teaching if the parent makes which statement? a) i should not force feed my child b) i should limit juice to 6 ounces per day c) i should feed my child if she will not eat d) i should limit snacks to two nutritious ones per day and give them only at my toddler's request
c) i should feed my child if she will not eat rationale toddlers have the skills required to feed themselves. children who can feed themselves should not be fed or force fed. to increase nutritious intake, juice intake is limited to 6 ounces per day and milk intake to 16 to 24 ounces per day. in addition, the nurse instructs the mother to limit nutritious snacks to two per day and to give them only at the toddler's request.
the nurse provides information to the mother of a toddler regarding toilet-training. the nurse should tell the mother what information? select all that apply -bladder control is usually achieved before bowel control -the child should not be forced to sit on the potty for long periods -the ability of the child to remove clothing is a sign of physical readiness -waiting until the child is 24-30 months old makes the task considerably easier -at the age of 24-30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents
the child should not be forced to sit on the potty for long periods // the ability of the child to remove clothing is a sign of physical readiness // waiting until the child is 24-30 months old makes the task considerably easier // at the age of 24-30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents rationale waiting until the child is 24-30 months old makes the task considerably easier because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents. bowel control typically occurs 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
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 rationale Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal morality. the other options are correct statements regarding Kohlberg's theory
a 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. the child is fearful of the hospitalization. which nursing intervention should the nurse suggest to alleviate the child's fears? a) encourage the child's parents to stay with the child b) encourage play with other children of the same age c) advise the family to visit only during the scheduled visiting hours d) provide a private room, allowing the child to bring favorite toys from home
a) encourage the child's parents to stay with the child rationale although the preschooler may already be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. the child may repeatedly ask when parents will be coming for a visit or may constantly want to call the parents. the second option is unrelated to the subject of the question and may not be appropriate for a child at risk for immunocompromise. the third option will increase stress related to separation anxiety. a private room may be necessary but this does not alleviate the child's fear
the nurse is caring for a 6-month-old infant. which developmental ability should the nurse expect to note in this infant? a) waves bye-bye b) uses gestures to communicate c) babbles using single consonants d) uses simple words such as "mama"
c) babbles using single consonants rationale using single-consonant babbling occurs between 6 and 8 months. between 8 and 9 months the infant begins to understand and obey simple commands such as wave bye-bye. using simple words such as "mama" and the use of gestures to communicate begin between 9 and 12 months
the parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. the mother states that this behavior began 2 days after hospital admission. which is the appropriate nursing response? a) it is best to ignore the behavior b) your child is acting like a baby c) the doctor will need to be notified d) a 4-year-old is too old for this type of behavior
a) it is best to ignore the behavior rationale in the hospitalized preschooler, it is best to accept regression if it occurs, because it is most often caused by 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. there is no need to call the hcp. the other two options are incorrect.
the parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. which instruction should the nurse reinforce to the parent? a) set limits on the child's behavior b) ignore the child when this behavior occurs c) allow the behavior, because this is normal at this age period d) punish the child every time the child says "no" to change the behavior
a) set limits on the childs behavior rationale according to Erikson, the child focuses on independence between the ages of 1 and 3 years. gaining independence often means that the child has to rebel against the parents wishes. saying things like "no" and "mine" and having temper tantrums are common during this period of development. being consistent and setting limits on the childs behavior are necessary elements. punishing the child every time the child says "no" is likely to produce a negative reponse
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 rationale in the formal operations stage, the child has the ability to think abstractly and solve problems. the third option identifies the sensorimotor stage. the last option identifies the preoperational stage
the parents of a 4-year-old child tell the nurse that they are concerned because the child has been 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 rationale according to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. at this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns. therefore, the other options are incorrect.
a mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. the nurse should make which suggestion to the mother? a) allow the bottle if it contains juice b) allow the bottle if it contains water c) do not allow the child to have the bottle d) allow the bottle during naps but not at bedtime
b) allow the bottle if it contains water rationale a toddler should not be allowed to fall asleep with a bottle because of the risk of dental caries. if the bottle is allowed in bed, it should contain only water
the nursing student is preparing a conference on Freud's psychosexual stages of development, specifically 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 rationale toilet training generally occurs during this period. according to Freud, the child gains pleasure from both the elimination and retention of feces. the first option relates to the oral stage. the third option relates to the latency period. the last option relates to the phallic stage
the nurse is evaluating the developmental level of a 2-year-old child. which should the nurse expect to observe in this child? a) uses a fork to eat b) holds a cup in one hand c) pours own milk into a cup d) uses a knife for cutting food
b) holds a cup in one hand rationale by 2 years of age, the child can hold a cup in one hand and use a spoon well. by the age of 3 to 4 years, the child begins to use a fork. by the end of the preschool period, the child should begin to use a knife for cutting. pouring liquids into a cup is a skill that requires fine motor development.
a client with sickle cell anemia has vaso-occlusive pain. after noting that the client is of preschool age, the nurse plans to use which method to determine the adequacy of pain control? a) ask the client to use a numerical rating scale of 0 to 10. b) institute the use of a patient-controlled analgesia (PCA) pump c) ask the client to point to faces (smiling to very sad) that best describe the pain d) ask the client to use a word descriptive rating scale (no, little, medium, large, worst pain)
c) ask the client to point to faces. (smiling to very sad) that best describe the pain rationale a client of preschool age has the cognitive ability to recognize happy and sad faces and to correlate them with the level of pain experienced. using descriptive words to communicate varying intensities of pain may be too complicated for some preschoolers. some preschool children may not be able to count or understand the value of numbers in relation to other numbers. children of preschool age are too young to control a CPA pump
the parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. which is the appropriate nursing response? a) you need to be concerned b) you need to monitor the child's behavior closely c) at this age, the child is developing his or her own personality d) you need to praise the child more often to stop this behavior
c) at this age, the child is developing his or her own personality rationale according to Erikson, at ages 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. the child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents. therefore, the other options identify incorrect responses
the nurse prepares to take a blood pressure on a school-age child. where should the nurse place the blood pressure cuff to obtain an accurate measurement? a) one half the distance between the antecubital fossa and the shoulder b) one third the distance between the antecubital fossa and the shoulder c) two thirds the distance between the antecubital fossa and the shoudler d) one quarter the distance between the antecubital fossa and the shoulder
c) two thirds the distance between the antecubital fossa and the shoulder rationale the size of the BP 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 the distance between the antecubital fossa and the shoulder
a 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. which intervention is most appropriate to facilitate normal growth and development? a) encourage the child to rest and read b) encourage the parents to room-in with the child c) allow the family to bring in favorite computer games d) allow the child to participate in activities with other individuals in the same age group when the condition permits
d) allow the child to participate in activities with other individuals in the same age group when the condition permits rationale adolescents are not often sure they want their parents with them when they are hospitalized. because of the importance of the peer group, separation from friends is a source of anxiety. ideally, the peer group will support the ill friend. the other options isolate the child from the peer group
the mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. the nurse should suggest which to the mother? a) avoid a nap during the day b) allow the child to set bedtime limits c) allow the child to have temper tantrums d) inform the child of bedtime a few minutes before it is time for bed
d) inform the child of bedtime a few minutes before it is time for bed rationale most toddlers take an afternoon nape and until approximately age 2, some also require a morning nap. toddlers often resist going to bed. firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics. bedtime protests may be reduced by warning the child of bedtime a few minutes before the time.
the parents of a 2-year-old arrive at the hospital to visit their child. the child is in the play room and ignores the parents during the visit. the nurse tells the parents that this behavior in a 2-year-old child indicates which? a) the child is withdrawn b) the child is upset with the parents c) the child is exhibiting a normal pattern d) the child has adjusted to the hospitalized setting
c) the child is exhibiting a normal pattern rationale the toddler is particularly vulnerable to separation. a toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home. the parents of hospitalized toddlers are frequently distressed by such behavior. the toddler normally engages in parallel play and plays alongside (but not with) other children. the other options are incorrect
according to Kohlberg's theory of moral development, at the preconventional level, moral development is thought to be motivated by which factor? a) peer pressure b) social pressures c) the parents behaviors d) punishment and reward
d) punishment and reward rationale in the preconventional level, morals are thought to be motivated by punishment and reward. if the child is obedient and not punished, then he or she is being moral. the child sees actions as either good or bad. if the child's actions are good, then the child is praised. if the childs actions are bad, then the child is punished.
which are components of Kohlberg's theory of moral development? select all that apply individuals move through all six stages in a sequential fashion moral development progresses in relation to cognitive development a persons 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 1 (punishment-obedience orientation), children are expected to reason as mature members of society in stage 2 (instrumental relativist orientation), the child conforms to rules to obtain rewards or to have favors returned
moral development progresses in relation to cognitive development // a persons 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 to have favors returned rationale Kohlbergs theory states that individuals move through the six stages of development in a sequential fashion but not everyone reaches stages 5 and 6 during his or her development of personal morality. the theory provides a framework for understanding how individuals determine a moral code to guide their behavior. it also states that moral development progresses in relation to cognitive development and a person's ability to make moral judgments develops over a period of time. in stage 1 (ages 2 to 3 years; punishment-obedience orientation). children cannot reason as mature members of society because they are too young to do so. in stage 2 (ages 4 to 7 years; instrumental relativist orientation), the child conforms to rules to obtain rewards or have favors returned
