NCLEX Review Chapter 19-21

The parents of a 16 yr old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response? 1. Adolescent love to sleep late in the morning 2. The child shouldn't be staying up so late at night 3. If the child eats properly that shouldn't be happening 4. The child needs to have a blood test to check for anemia

1. Adolescent love to sleep late in the morning

Upon palpation of the fontanel of a 3 month old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action would the nurse take? 1. Increase oral fluids 2. Document the findings 3. Notify the RN 4. Elevate the head of the bed to 90 degrees

2. Document the findings

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about theory? 1. All individuals move through all six stages in a sequential fashion 2. Moral development progresses in relation to cognitive development 3. A person's ability to make moral judgements develops over a period of time 4. It provides a framework for understanding how individuals determine a moral code to guide his or her behavior

1. All individuals move through all six stages in a sequential fashion

The nurse student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately related to this stage? 1. Gratification of self 2. Beginning of toilet training 3. Tapering off of conscious biological and sexual urges 4. Association with pleasurable and conflicting feeling about the genital organs

2. Beginning of toilet training

The nurse is caring for an older client who is reminiscing about past life experience in a positive manner. The nurse plans care with the understanding that this behavior indicates which of the following? 1. A mental status alteration 2. A normal psychosocial response 3. A need for psychiatric consultation 4. A sensory deficit requiring social activities

2. A normal psychosocial response

When caring for a 3 yr old child, the nurse would provide which toy for the child? 1. A puzzle 2. A wagon 3. A golf set 4. A miniature farm set

2. A wagon

The nurse is caring for a 5 yr old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child? 1. Blocks 2. A music video 3. A 10 piece puzzle 4. Large picture books

3. A 10 piece puzzle

Which client is most likely at risk to become a victim of elder abuse? 1. A 75 yr old man with moderate hypertension 2. A 68 yr old man with newly diagnosed cataracts 3. A 90 yr old woman with advanced Alzheimer's disease 4. A 70 yr old women with early diagnosed Lyme disease

3. A 90 yr old woman with advanced Alzheimer's disease

Which intervention needs to be implemented for the older client with presbycusis who has a hearing loss? 1. Speak louder 2. Speak more slowly 3. Use low-pitched tones 4. Use high-pitched tones

3. Use low-pitched tones

A 16 yr 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? 1. Encourage the child to rest and read 2. Encourage the parents to room-in with child 3. Allow family to bring in favorite computer games 4. Allow the child to participate in activities with other individuals in the same age group when the condition permits

4. Allow the child to participate in activities with other individuals in the same age group when the condition permits

The parents of an 8 yr 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? 1. You need to be concerned 2. You need to monitor the child's behavior closely 3. You need to praise the child more often to stop this behavior 4. At this age, the child is developing his or her own personality

4. At this age, the child is developing his or her own personality

A child remarks, "I share my toys and snack with my friends so they will like me more. The nurse determines the child is in which state of moral development? 1. Egocentric judgement 2. Law-and-order orientation 3. Good boy-nice boy orientation 4. Social contract and legalistic orientation

3. Good boy-nice boy orientation

The nurse would implement which activity to promote reminiscence among older clients? 1. Having storytelling hours 2. Setting up pet therapy sessions 3. Displaying calendars and clocks 4. Encouraging client participation in a pottery class

1. Having storytelling hours

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply 1. Looks at old snapshots of family 2. Constantly neglects personal grooming 3. Visits the spouse's grave once a month 4. Visits the senior citizen's center once a month 5. Prefers to spend time alone and avoids contact with others

1. Looks at old snapshots of family 3. Visits the spouse's grave once a month 4. Visits the senior citizen's center once a month

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 1. Discourage reminiscing 2. Make the decisions for the family 3. Encourage expression of feelings, concerns, and fears 4. Explain everything that is happening to all family members 5. Touch and hold the client's or family member's hand if appropriate 6. Be honest and let the client and family know that they will not be abandoned by the nurse

3. Encourage expression of feelings, concerns, and fears 5. Touch and hold the client's or family member's hand if appropriate 6. Be honest and let the client and family know that they will not be abandoned by the nurse

The parent of a 4 yr 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? 1. Your child is acting like a baby 2. The doctor will need to be notified 3. This is common during hospitalization 4. A 4 yr old is too old for this type of behavior

3. This is common during hospitalization

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention would be implemented initially? 1. Stand in front of the client 2. Exaggerate lip movements 3. Obtain a sign-language interpreter 4. Pantomime and write the client notes

1. Stand in front of the client

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how would the nurse position the client? 1. Upright in a chair 2. In the left side in bed 3. On the right in bed 4. In a low Fowler's position, with the legs elevated

1. Upright in a chair

The parent of a 3 yr old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction would the nurse reinforce to the parents? 1. Set limits on the child's behavior 2. Ignore the child when this behavior occurs 3. Allow the behavior because this is normal at this is age period 4. Punish the child every time the child says no to change the behavior

1. Set limits on the child's behavior

The nurse notes that a 6 yr 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? 1. Move the objects in the child's direct field of vision 2. Teach the child how to visually scan the environment 3. Report the observation to the PHCP 4. Provide additional lighting for the child during play activities

3. Report the observation to the PHCP

The parents of a 2 yr old arrive at the hospital to visit their child. The child is in the playroom and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2 yr old indicates which characteristic about the child? 1. The child is withdrawn 2. The child is upset with the parents 3. The child is exhibiting a normal pattern 4. The child has adjusted to the hospitalized setting

3. The child is exhibiting a normal pattern

An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity? 1. Decreased salivation and gastrointestinal motility 2. Decreased muscle strength and loss of bone density 3. Decreased lean body mass and glomerular filtration rate 4. Decreased cardiac output and decreased efficiency of blood return to the heart

3. Decreased lean body mass and glomerular filtration rate

The nurse would plan which to encourage autonomy in the client who is a resident in a long-term care facility? 1. Choosing meals 2. Decorating the room 3. Scheduling haircut appointments 4. Allowing the client to choose social activities

4. Allowing the client to choose social activities

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction would the nurse reinforce to the parents? 1. Allow the infant to signal a need 2. Anticipate all of the needs of the infant 3. Attend to the crying infant immediately 4. Avoid the infant during the first 10 minutes of crying

1. Allow the infant to signal a need

When the nurse is collecting data from the older adult, which findings would be considered normal physiological changes? Select all that apply 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to UTIs 6. Increased incidence of awakening after sleeping onset

2. Decline in visual acuity 5. Increased susceptibility to UTIs 6. Increased incidence of awakening after sleeping onset

The nurse is determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? 1. I know all my mulplication tables by memory 2. The ball is gone, when a ball disappears out of sight 3. I'll use a map to help me find my way in a new town 4. The moon follows me and goes to bed when I go to bed

4. The moon follows me and goes to bed when I go to bed

The nurse is observing a parent a 3 yr old child interacting in the clinic waiting room. The child beings to bounce in the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development? 1. Egocentric judgment 2. Law-order-orientation 3. Punishment-obedience state 4. Good boy-nice girl orientation

3. Punishment-obedience state

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance? 1. Gardening every day for an hour 2. Sculpting once a week for 40 minutes 3. Cycling three times a week for 20 minutes 4. Walking three to five times a week for 30 minutes

4. Walking three to five times a week for 30 minutes

The nurse is reinforcing discharge instructions to the parents of a 2 yr old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement? 1. We will be sure not to leave hot liquids unattended 2. I guess my child needs to understand what the word hot means 3. We will be sure that our child stays in his room when we work in the kitchen 4. We will install a safety gate as soon as we get home so that our child can't get into the kitchen

1. We will be sure not to leave hot liquids unattended

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 naptime 4. Hang mobiles with black-and-white contrast designs 5. Cares 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. Cares the infant while bathing or during diaper changes