NCLEX-RN
The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do!" After the nurse teaches the parent about ways to manage this behavior, which statement by the parent indicates that the nurse's teaching was successful? "Next time she screams and throws her legs, I'll ignore the behavior." "I'll allow her to have what she wants once in a while." "I'll explain why she cannot have what she wants." "When she behaves like this, I'll tell her that she is being a bad girl."
The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child's behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering with the child's ability to develop a sense of autonomy.
During the second day postpartum, the nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with a little assistance from her partner. According to Reva Rubin's "phases of bonding," which of the following is the appropriate phase the woman is experiencing? the taking-in phase the taking-hold phase the binding-in phase the letting-go phase
The taking-in phase is the period after birth characterized by the women's dependency and passivity with others. Maternal needs are dominant and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is the period after birth characterized by a woman becoming more independent and most interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together.
A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? keeping plastic liners in the brassiere to keep the nipple drier placing as much of the areola as possible into the baby's mouth smoothly pulling the nipple out of the mouth after 10 minutes removing any remaining milk left on the nipple with a soft washcloth
Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple soreness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 minutes may prevent the baby from getting the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off because the milk has healing properties.
A parent tells the nurse that the primary discipline method used in the home is corporal punishment. What should the nurse tell the parent about corporal punishment? It does not physically harm the child. Use can result in children becoming accustomed to spanking. It reinforces the idea that violence is not acceptable. Use can be beneficial in teaching children what they should do.
Corporal punishment is an aversion technique that teaches children what not to do. Children can commonly become accustomed to physical punishment, so the punishment must be more severe to get the same results. Parents commonly use physical punishment when they are in a rage; injury to the child can result. Corporal punishment, such as spanking, can reinforce the idea that violence is acceptable in certain circumstances. Corporal punishment is not beneficial. It causes children to be fearful and may lead children to redirect their anger in destructive ways. Add a Note
A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period? 12 hours 24 hours 2 to 4 days 7 days
If the client begins breastfeeding early and often after birth, the breasts begin to fill with milk within 48 to 96 hours, or 2 to 4 days. The breasts secrete colostrum for the first 24 to 48 hours, which is beneficial to the neonate because of the immunoglobulins contained in colostrum.
A community nurse is working with the family of an infant and teaching the parents about preventative health practices. Which of the following is a priority for the nurse to include in the teaching? introducing screening tests testing suck reflexes testing grasp reflexes measuring sleep patterns
Introducing screening tests is an important part of preventative health because the tests identify the presence of a health condition before symptoms are evident.
A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: 2 to 3 months. 6 to 8 months. 9 to 10 months. 12 to 18 months.
Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in an intellectual disability. The posterior fontanel typically closes by ages 2 to 3 months.
When developing the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery, which method is most appropriate? Tell the child that his penis and scrotum will be "fixed." Explain to the parents how the defect will be corrected. Tell the child that he will not see any incisions after surgery. Use an anatomically correct doll to show the child what will be "fixed."
Preoperative teaching would be directed at the parents because the child is too young to understand the teaching. Telling the child that his penis and scrotum will be "fixed," telling the child he will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate interventions for a preschool-age child.
The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's best action? Document the findings in the newborn's chart. Contact the pediatrician immediately. Expect the newborn to have an elevated bilirubin level. Ensure that the hearing screening exam is done immediately
Strabismus is a normal finding during the newborn stage and the finding should be documented. There is no association with bilirubin levels and hearing screenings with strabismus.
A parent says that her family will soon be traveling abroad and asks why the drinking water in many regions must be boiled. The nurse should explain that, in addition to various types of dysentery, contaminated drinking water is most commonly responsible for the transmission of which disease? yellow fever brucellosis poliomyelitis typhoid fever
Water is the usual vehicle for spreading typhoid fever.Yellow fever is spread through insect bites.Brucellosis (undulant fever) is spread by contaminated cow's milk.Poliomyelitis is most probably spread through respiratory secretions.
The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse? "Hold the bottle vertically so that the milk flows easily and the baby does not need to suck hard." "Keep the nipple full of milk throughout the feeding." "Burp the newborn only after the baby has finished the bottle." "Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks."
Paced bottle feeding allows the premature infant to have more control with feeding and mimics more natural feeding. The baby can pause and take a break when needed. The bottle is held nearly horizontal when it's in the infant's mouth. This way the milk won't pour into the newborn as it would with holding the bottle vertically or keeping the nipple full of milk. The baby should be burped at least once during the feeding to remove air bubbles.
The nurse is assessing a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply. holding head erect self-feeding with a spoon demonstrating good bowel and bladder control sitting on a firm surface without support bearing majority of weight on legs walking alone
By age 4 months, an infant would be able to hold the head erect. By age 9 months, the infant would be able to sit on a firm surface without support and bear the majority of weight on the legs (for example, walking while holding onto furniture). Self-feeding and bowel and bladder control are developmental milestones of toddlers. By age 12 months, the infant would be able to stand alone and may take the first steps.
Which situation indicates that more teaching is needed when a 10-year-old is hospitalized for the first time? The parents choose to leave to let the child build a relationship with the staff. The parents relate readily with the staff and calmly with the child. The child accepts and responds positively to comforting measures. The child discusses procedures and activities without evidence of anxiety.
The parents leaving indicates more teaching is needed. The parents of an adolescent might leave to help the child maintain a fragile identity, but a 10-year-old child would prefer to have his parents with him. Expected outcomes of support and teaching for a child and parents new to the hospital would include the parents' relating readily to the staff and calmly with the child, the child accepting and responding positively to comforting measures, and the child discussing procedures and activities without evidence of anxiety.
A parent voices concern to the nurse that a 2-year-old toddler never seems to want to play with other children at the park. What would be the nurse's best response? "Don't worry, it's probably because your child is shy." "That is considered normal at this age." "You should arrange a play date with another toddler." "You should model playing behaviors for your child."
Two-year-olds engage in parallel play, in which they play side by side but rarely interact. Associative play is characteristic of preschoolers, in which they are all engaged in a similar activity but with little organization. School-age children engage in cooperative play, which is organized and goal-directed. Children do not need to have play modeled for them. The ability to play and interact with other children will improve as the child grows.
Which approach by a nurse is the best for trying to take a crying toddler's temperature? Ignore the crying and screaming. Tell the caregiver not to hold the client. Talk to the caregiver first and then to the client. Bring extra help so it can be done quickly.
When dealing with a crying client, the best approach is to talk to the caregiver first then to the toddler. This approach helps the client get used to the nurse before attempting any procedures. It also gives the client an opportunity to see that the caregiver trusts the nurse. Ignoring the crying and screaming may be the second step. The nurse should encourage the caregiver to hold the client because it will likely help the situation. The last resort is to bring in assistance so the procedure can be completed quickly.
A client brings her 6-month-old infant in for a well-baby visit. During the exam, the nurse is unable to elicit the Moro reflex. Which is the appropriate action by the nurse? explaining to the client that this reflex disappears around 3-4 months contacting the physician with the finding waiting 5 minutes then attempting to elicit the reflex again explaining that this reflex disappears around 6-8 weeks
The Moro reflex disappears around 3-4 months of age; therefore, it is considered a normal finding for it not to be elicited in a 6-month-old infant. The nurse should explain to the parent that the reflex disappears around 3-4 months. There is no need to attempt to elicit the reflex again or to contact the physician with the finding.
A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next? Use the McDonald procedure to widen the pelvic opening. Increase the rate of oxygen and intravenous fluids. Instruct the client to use a pant-blow pattern of breathing. Tell the client to push only when absolutely necessary.
Pushing during the first stage of labor, when the urge is felt but the cervix is not completely dilated, may produce cervical swelling, making labor more difficult. The client should be encouraged to use a pant-blow (or blow-blow) pattern of breathing to help overcome the urge to push. The McDonald procedure is used for cervical cerclage for an incompetent cervix and is inappropriate here. Increasing the rate of oxygen and intravenous fluids will not alleviate the pressure that the client is feeling. The client should not push even if she feels the urge to do so because this may result in cervical edema at 7-cm dilation.
When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier: provides an outlet for emotional tension. indicates readiness to take solid foods. indicates intestinal motility. is an attempt to get attention from the parents.
Sucking provides the infant with a sense of security and comfort. It also is an outlet for releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant's appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention.
What recommendation should the nurse give a family about appropriate beverages for children? Give children whole milk until 5 years of age. It is better to give your child bottled water rather than tap water. Offering sports drinks is the ideal way to provide hydration during physical activity. Sugary drinks, including juice, should be avoided.
Sugary drinks contain empty calories and considered to be a major factor in the childhood obesity epidemic. Juice should be limited to no more than 120 to 180 mL per day. Water from community sources is more likely to contain fluoride that promotes dental health than bottled water. Sports drinks are considered sugary drinks. Unless a child has had excessive fluid loss, water is all that is needed to stay hydrated during physical activity.
A client had a cast applied to the left femur to stabilize a fracture. To promote early rehabilitation, what should the nurse do? Call physical therapy to provide passive exercise of the affected limb. Teach the client how to do isometric exercise of the quadriceps. Show the family how to do active range-of-motion exercises of the unaffected limb. Obtain weights so the client can exercise the upper extremities.
The nurse should teach the client how to do isometric exercise, contraction of the quadriceps muscle without movement of joint, to maintain muscle strength. Physical therapy may assist the client later, and will then teach the client how to do active exercises and crutch walking if prescribed. The client will be able to move the unaffected limb; the family will not need to assist. If the client will be using crutches, building upper extremity strength will be helpful, but the immediate need is to maintain and develop strength in the quadriceps.
To promote comfort and optimal respiratory expansion for a client with chronic obstructive pulmonary disease during sexual intimacy, the nurse can suggest the couple do what? Use a nasal decongestant inhaler. Raise the affected partner's head and upper torso on pillows. Have the affected partner assume a dependent position. Limit the duration of the sexual activity.
Raising the upper torso for the affected partner facilitates respiratory function. The client should not use inhalers that are not a part of the treatment plan, and if the client's health is well managed, it is not necessary to take additional medications to improve respiratory function. A dependent position may compromise respiratory expansion, even though energy may be conserved. Duration of sexual activity is not necessarily related to exertion.
A client is diagnosed with human immunodeficiency virus (HIV). What information does the nurse provide to best protect the client from advancing to the acquired immunodeficiency syndrome (AIDS) phase of this infection? Engage in safer-sex practices at all times. Strictly adhere to antiviral medication therapy. Practice meticulous infection control. Maintain a generally healthy lifestyle.
Antiretroviral therapy (ART) can control HIV and prevent the progression to AIDS. Missing doses of this therapy greatly increases the risk for increased viral activity. Making healthy lifestyle choices is good general advice but does not control viral activity as ART will. The client is not at high risk for contracting opportunistic infections simply by being HIV positive; the degree of risk depends on current cell counts. Once in the AIDS stage of infection, the client is at high risk for infection and needs to take protective measures. Safe sexual practices protect others from the virus.
A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask which question? "Have you ever had osteomyelitis?" "Do you have any cats at home?" "Do you have any birds at home?" "Have you recently had a rubeola vaccination?"
TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus — agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.
