Nur214 Exam 1
A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to A increase her fluid intake to three liters/day. B request a prescription for a laxative from her physician. C stop taking iron supplements. D take two tablespoons of mineral oil daily.
A In pregnancy, constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy, as ordered, and should not be discontinued.
The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which of the following is the most appropriate suggestion to the mother? Do not allow the child to have the bottle Allow the bottle during naps but not at bedtime Allow the bottle if it contains juice Allow the bottle if it contains water
A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk or nursing caries. If a bottle is allowed at naptime or bedtime, it should contain only water
The nurse observes a 10-month-old infant using her index finger and thumb to pick up pieces of cereal. This behavior is evidence that the infant has developed: a. the pincer grasp. b. a grasp reflex. c. prehension ability. d. the parachute reflex
ANS: A By 1 year, the pincer-grasp coordination of index finger and thumb is well established.
In terms of fine motor development, the infant of 7 months should be able to: a. Transfer objects from one hand to the other. b. Use thumb and index finger in crude pincer grasp. c. Hold crayon and make a mark on paper. d. Release cubes into a cup.
ANS: A By age 7 months infants can transfer objects from one hand to the other, crossing the midline. The crude pincer grasp is apparent at about age 9 months. The child can scribble spontaneously at age 15 months. At age 12 months the child can release cubes into a cup.
In terms of cognitive development the 5-year-old child would be expected to: a. Use magical thinking. b. Think abstractly. c. Understand conservation of matter. d. Be unable to comprehend another person's perspective.
ANS: A Magical thinking is believing that thoughts can cause events. Abstract thought does not develop until school-age years. The concept of conservation is the cognitive task of school-age children ages 5 to 7 years. Five-year-olds cannot understand another's perspective.
In terms of gross motor development, what would the nurse expect a 5-month-old infant to do? a. Roll from abdomen to back. b. Roll from back to abdomen. c. Sit erect without support. d. Move from prone to sitting position.
ANS: A Rolling from abdomen to back is developmentally appropriate for a 5-month-old infant. The ability to roll from back to abdomen usually occurs at 6 months old. Sitting erect without support is a developmental milestone usually achieved by 8 months. The 10-month-old infant can usually move from a prone to a sitting position.
An adolescent girl tells the nurse that she is very suicidal. The nurse asks her if she has a specific plan. Asking this should be considered: a. An appropriate part of the assessment. b. Not a critical part of the assessment. c. Suggesting that the adolescent needs a plan. d. Encouraging the adolescent to devise a plan.
ANS: A Routine health assessments of adolescents should include questions that assess the presence of suicidal ideation or intent. Questions such as, "Have you ever developed a plan to hurt yourself or kill yourself" should be part of that assessment. Threats of suicide should always be taken seriously and evaluated. Suggesting that the adolescent needs a plan and encouraging them to devise this plan are inappropriate statements by the nurse.
The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. The nurse should recommend that the parents: a. Ignore the "baby talk." b. Explain to the toddler that "baby talk" is for babies. c. Tell the toddler frequently, "You are a big kid now." d. Encourage the toddler to practice more advanced patterns of speech.
ANS: A The baby talk is a sign of regression in the toddler. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is children's way of saying that they are expressing stress. The parents should not introduce new expectations and should allow the child to master the developmental tasks without criticism.
The parent of a 3-month-old infant asks the nurse, "At what age do infants usually begin drinking from a cup?" The nurse would reply: a. 5 months. b. 9 months. c. 1 year. d. 2 years.
ANS: A The infant can usually drink from a cup when it is offered at about 5 months.
What represents the major stressor of hospitalization for children from middle infancy throughout the preschool years? a. Separation anxiety b. Loss of control c. Fear of bodily injury d. Fear of pain
ANS: A The major stress for children from infancy through the preschool years is separation anxiety, also called anaclitic depression. This is a major stressor of hospitalization. Loss of control, fear of bodily injury, and fear of pain are all stressors associated with hospitalization. However, separation from family is a primary stressor in this age group.
A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as: a. Normal development. b. Significant developmental lag. c. Slightly delayed development caused by prematurity. d. Suggestive of a neurologic disorder such as cerebral palsy.
ANS: A This indicates normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. No evidence of neurologic dysfunction is present.
A parent of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse's best interpretation of this behavior is that: a. This is normal behavior for his age. b. This is unusual behavior for his age. c. He is not effectively coping with stress. d. He is showing he needs more attention.
ANS: A Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and the use of the word "no." Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18-month-old.
The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)? Select all that apply. a. Irritability b. Ineffective feeding patterns c. No predictable sleep-wake cycle d. Distrust e. Effective parent bonding
ANS: A, B, C, D Children who experience frequent hunger do not have effective parental bonding. All other options are probable outcomes for a child who has unmet hunger needs.
What should the teaching plan include about infant fall precautions? Select all that apply. a. Remove all unsteady furniture. b. Keep crib rails up and in locked position. c. Steady infant with hand when on changing table. d. Use tray attachment on high chair as restraint. e. Keep infant seat on the floor
ANS: A, B, C, E The tray attachment to a high chair is an inadequate restraint. All other options are good precautions to prevent an infant from a fall.
The parent of a 4-year-old son tells the nurse that the child believes "monsters and boogeyman" are in his bedroom at night. The nurse's best suggestion for coping with this problem is to: a. Insist that the child sleep with his parents until the fearful phase passes. b. Suggest involving the child to find a practical solution such as a night light. c. Help the child understand that these fears are illogical. d. Tell the child frequently that monsters and boogeyman do not exist
ANS: B A night light shows a child that imaginary creatures do not lurk in the darkness. Letting the child sleep with parents will not get rid of the fears. A 4-year-old is in the preconceptual age and cannot understand logical thought.
What describes a toddler's cognitive development at age 20 months? a. Searches for an object only if he or she sees it being hidden b. Realizes that "out of sight" is not out of reach c. Puts objects into a container but cannot take them out d. Understands the passage of time such as "just a minute" and "in an hour"
ANS: B At this age the child is in the final sensorimotor stage. Children will now search for an object in several potential places, even though they saw only the original hiding place. Children have a more developed sense of objective permanence. They will search for objects even if they have not seen them hidden. Putting an object in a container but being able to take it out indicates tertiary circular reactions. An embryonic sense of time exists, although the children may behave appropriately to time-oriented phrases; their sense of timing is exaggerated.
A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least _____ pounds. a. 12 b. 16 c. 20 d. 24
ANS: B Birth weight is usually doubled by 6 months of age.
Which statement best describes fear in school-age children? a. They are increasingly fearful for body safety. b. Most of the new fears that trouble them are related to school and family. c. They should be encouraged to hide their fears to prevent ridicule by peers. d. Those who have numerous fears need continuous protective behavior by parents to eliminate these fears.
ANS: B During the school-age years children experience a wide variety of fears, but new fears related predominantly to school and family bother children during this time. During the middle-school years children become less fearful of body safety than they were as preschoolers. Parents and other persons involved with children should discuss their fear with them individually or as a group activity. Sometimes school-age children hide their fears to avoid being teased. Hiding the fears does not end them and may lead to phobias.
Which statement accurately describes physical development during the school-age years? a. The child's weight almost triples. b. A child grows an average of 2 inches per year. c. Few physical differences are apparent among children at the end of middle childhood. d. Fat gradually increases, which contributes to the child's heavier appearance
ANS: B In middle childhood growth in height and weight occur at a slower pace. Between the ages of 6 to 12 years, children grow 2 inches per year. In middle childhood children's weight will almost double; they gain 3 kg/year. At the end of middle childhood girls grow taller and gain more weight than boys. Children take on a slimmer look with longer legs in middle childhood.
What is descriptive of the play of school-age children? a. Individuality in play is better tolerated than at earlier ages. b. Knowing the rules of a game gives an important sense of belonging. c. They like to invent games, making up the rules as they go. d. Team play helps children learn the universal importance of competition and winning.
ANS: B Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play children learn about competition and the importance of winning, an attribute highly valued in the United States.
A 4-year-old boy is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was "bad." The nurse's best interpretation of this comment is that it is: a. A sign of stress. b. Common at this age. c. Suggestive of maladaptation. d. Suggestive of excessive discipline at home.
ANS: B Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them think that they are directly responsible for events, making them feel guilt for things outside of their control. Children of this age show stress by regressing developmentally or acting out. Maladaptation is unlikely. This comment does not imply excessive discipline at home.
According to Erikson, the psychosocial task of adolescence is developing: a. Intimacy. b. Identity. c. Initiative. d. Independence
ANS: B Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Initiative is the developmental stage for early childhood. Independence is not one of Erikson's developmental stages.
Which statement is correct about toilet training? a. Bladder training is usually accomplished before bowel training. b. Wanting to please the parent helps motivate the child to use the toilet. c. Watching older siblings use the toilet confuses the child. d. Children must be forced to sit on the toilet when first learning.
ANS: B Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please the parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.
The nurse explains that by the age of 6 months an iron-rich formula should be offered because the infant has: a. limited ability to produce red blood cells. b. ineffective digestive enzymes. c. exhausted maternal iron stores. d. need of the iron to support dentition
ANS: C
The nurse would expect a 4-month-old to be able to: a. hold a cup. b. stand with assistance. c. lift head and shoulders. d. sit with back straight
ANS: C Because development is cephalocaudal, of these choices, lifting the head and shoulders is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months.
Most infants begin to fear strangers at age: a. 2 months b. 4 months c. 6 months d. 12 months
ANS: C Between ages 6 and 8 months fear of strangers and stranger anxiety become prominent and are related to the infant's ability to discriminate between familiar and nonfamiliar people. At age 2 months infants are just beginning to respond differentially to the mother. At age 4 months the infant is beginning the process of separation individuation when the infant begins to recognize self and mother as separate beings. Twelve months is too late and requires referral for evaluation if the child does not fear strangers at this age.
Although a 14-month-old girl received a shock from an electrical outlet recently, her parents find her about to place a paper clip in another outlet. The best interpretation of this behavior is: a. Her cognitive development is delayed. b. This is typical behavior because toddlers are not very developed. c. This is typical behavior because of inability to transfer knowledge to new situations. d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain.
ANS: C During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The slot of an outlet is for putting things into. Her cognitive development is appropriate for her age and represents typical behavior for a toddler. Only some awareness exists of a causal relation between events.
A group of boys ages 9 and 10 years have formed a "boys-only" club that is open to neighborhood and school friends who have skateboards. This should be interpreted: a. Behavior that encourages bullying and sexism. b. Behavior that reinforces poor peer relationships. c. Characteristic of social development of this age. d. Characteristic of children who later are at risk for membership in gangs
ANS: C One of the outstanding characteristics of middle childhood is the creation of formalized groups or clubs. Peer-group identification and association are essential to a child's socialization. Poor relationships with peers and a lack of group identification can contribute to bullying. A boys-only club does not have a direct correlation with later gang activity.
The most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old would be to: a. ride a tricycle. b. spend time in an infant swing. c. play with push-pull toys. d. read large picture books
ANS: C Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old child.
When assessing development in a 9-month-old infant, the nurse would expect to observe the infant: a. speaking in 2-word sentences. b. grasping objects with palmar grasp. c. creeping along the floor. d. beginning to use a spoon rather sloppily
ANS: C The 9-month-old tries to creep, has developed pincer movement, and can grasp a spoon without keeping food on it.
The nurse is aware that the earliest age at which an infant is able to sit steadily alone is _____ months. a. 4 b. 5 c. 8 d. 15
ANS: C The infant can sit alone without support at about 8 months of age
The abnormal finding in an evaluation of growth and development for a 6-month-old infant would be: a. weight gain of 4 to 7 ounces per week. b. length increase of 1 inch in 2 months. c. head lag present. d. can sit alone for a few seconds
ANS: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation.
Peer relationships become more important during adolescence because: a. Adolescents dislike their parents. b. Adolescents no longer need parental control. c. They provide adolescents with a feeling of belonging. d. They promote a sense of individuality in adolescents.
ANS: C The peer group serves as a strong support to teenagers, providing them with a sense of belonging and strength and power. During adolescence the parent/child relationship changes from one of protection-dependency to one of mutual affection and quality. Parents continue to play an important role in the personal and health-related decisions. The peer group forms the transitional world between dependence and autonomy.
What would the nurse expect of a healthy 3-year-old child? a. Jump rope b. Ride a two-wheel bicycle c. Skip on alternate feet d. Balance on one foot for a few seconds
ANS: D 3-year-olds are able to accomplish the gross motor skill of balancing on one foot. Jumping rope, riding a two-wheel bike, and skipping on alternative feet are gross motor skills of 5-year-old children
The statement made by a parent that indicates correct understanding of infant feeding is: a. "I've been mixing rice cereal and formula in the baby's bottle." b. "I switched the baby to low-fat milk at 9 months." c. "The baby really likes little pieces of chocolate." d. "I give the baby any new foods before he takes his bottle."
ANS: D New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods.
A mother calls the pediatrician's office because her infant is "colicky." The helpful measure the nurse would suggest to the parent is to: a. sing songs to the infant in a soft voice. b. place the infant in a well-lit room. c. walk around and massage the infant's back. d. rock the fussy infant slowly and gently.
ANS: D One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements.
The nurse would advise a parent when introducing solid foods to: a. begin with one tablespoon of food. b. mix foods together. c. eliminate a refused food from the diet. d. introduce each new food 4 to 7 days apart.
ANS: D Only one new food is offered in a 4- to 7-day period to determine tolerance.
The role of the peer group in the life of school-age children is that it: a. Gives them an opportunity to learn dominance and hostility. b. Allows them to remain dependent on their parents for a longer time. c. Decreases their need to learn appropriate sex roles. d. Provides them with security as they gain independence from their parents.
ANS: D Peer-group identification is an important factor in gaining independence from parents. Through peer relationships children learn ways to deal with dominance and hostility. They also learn how to relate to people in positions of leadership and authority and explore ideas and the physical environment. Peer-group identification helps in gaining independence rather than remaining dependent. A child's concept of appropriate sex roles is influenced by relationships with peers.
Which characteristic best describes the gross motor skills of a 24-month-old child? a. Skips b. Rides tricycle c. Broad jumps d. Walks up and down stairs
ANS: D The 24-month-old child can go up and down stairs alone with two feet on each step. Skipping and the ability to broad jump are skills acquired at age 3. Tricycle riding is achieved at age 4.
An adolescent boy tells the nurse that he has recently had homosexual feelings. The nurse's response should be based on knowledge that: a. This indicates that the adolescent is homosexual. b. This indicates that the adolescent will become homosexual as an adult. c. The adolescent should be referred for psychotherapy. d. The adolescent should be encouraged to share his feelings and experiences.
ANS: D These adolescents are at increased risk for health-damaging behaviors, not because of the sexual behavior itself, but because of society's reaction to the behavior. The nurse's first priority is to give the young man permission to discuss his feelings about this topic, knowing that the nurse will maintain confidentially, appreciate his feelings, and remain sensitive to his need to talk it. In recent studies among self-identified gay, lesbian, and bisexual adolescents, many of the adolescents report changing their self-labels one or more times during their adolescence.
The school nurse has been asked to begin teaching sex education in the 5th grade. The nurse should recognize that: a. Children in 5th grade are too young for sex education. b. Children should be discouraged from asking too many questions. c. Correct terminology should be reserved for children who are older. d. Sex can be presented as a normal part of growth and development.
ANS: D When sex information is presented to school-age children, sex should be treated as a normal part of growth and development. Fifth graders are usually 10 to 11 years old. This age is not too young to speak about physiologic changes in their bodies. They should be encouraged to ask questions. Preadolescents need precise and concrete information.
The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be MOST effective in meeting the growth and development needs for persons in this age group? A Aerobic exercise classes B Transportation for shopping trips C Reminiscence groups D Regularly scheduled social activities
According to Erikson"s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss.
A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to Allow the newborn infant to signal a need Anticipate all of the needs of the newborn infant Avoid the newborn infant during the first 10 minutes of crying Attend to the newborn infant immediately when crying
According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn's signal would inhibit the development of trust and lead to mistrust of others.
A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. The nurse most appropriately tells the mother to: A. Punish the child every time the child says "no", to change the behavior B. Allow the behavior because this is normal at this age period C. Set limits on the child's behavior D. Ignore the child when this behavior occurs
According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are the necessary elements.
The nurse is planning care for an 18 month-old child. Which of the following should be included the in the child's care? A Hold and cuddle the child often B Encourage the child to feed himself finger food C Allow the child to walk independently on the nursing unit D Engage the child in games with other children
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living.
Which stage of development is most unstable and challenging regarding development of personal identity? Adolescence Toddler hood Childhood Infancy
Adolescence
The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first? a. Auscultation b. Inspection c. Percussion d. Palpation
Answer B. Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it's typically due to: a. A neck tumor b. An electrolyte imbalance c. Dehydration d. Fluid overload
Answer D. Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn't typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn't directly contribute to jugular vein distention.
Which type of play is most typical of the preschool period? a. Solitary b. Parallel c. Associative d. Team
Associative play is group play in similar or identical activities but without rigid organization or rules. Solitary play is that of infants. Parallel play is that of toddlers. School-age children play in teams.
The nurse is assessing a six-month-old child. Which developmental skills are normal and should be expected? A Speaks in short sentences. B Sits alone. C Can feed self with a spoon. D Pulling up to a standing position
B The child develops language skills between the ages of one and three. A six-month-old child is learning to sit alone. The child begins to use a spoon at 12-15 months of age. The baby pulls himself to a standing position about ten months of age.
The nurse teaches parents how to help their children learn impulse control and cooperative behaviors. This would occur during which of the stages of development defined by Erikson? A.Trust versus mistrust B.Initiative versus guilt C.Industry versus inferiority D.Autonomy vs. Shame and doubt
B) Initiative vs Guilt. The stage of initiative versus guilt occurs from ages 3 to 6 years, during which children develop direction and purpose. Teaching impulse control and cooperative behaviors during this stage help the child to avoid risks of altered growth and development. In the autonomy versus sense of shame and doubt stage, toddlers learn to achieve self-control and willpower. Trust versus mistrust is the first stage, during which children develop faith and optimism. During the industry versus inferiority stage, children develop a sense of competency
A nurse is evaluating the developmental level of a 2-year-old. Which of the following does the nurse expect to observe in this child? Uses a fork to eat Uses a cup to drink Uses a knife for cutting food Pours own milk into a cup
By age 2 years, the child can use a cup and can use a spoon correctly but with some spilling. By ages 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting
The nurse is caring for the mother of a newborn. The nurse recognizes that the mother needs more teaching regarding cord care because she A keeps the cord exposed to the air. B washes her hands before sponge bathing her baby. C washes the cord and surrounding area well with water at each diaper change. D checks it daily for bleeding and drainage.
C Exposure to air helps dry the cord. Good hand washing is the prime mechanism for preventing infection. Washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to infection. It is important to check for complications of bleeding and drainage that might occur.
A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. The nurse most appropriately tells the mother to: A) Punish the child every time the child says "no", to change the behavior B) Allow the behavior because this is normal at this age period C) Set limits on the child's behavior D) Ignore the child when this behavior occurs
C) Set limits on the child's behavior-According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are the necessary elements.
The nurse is caring for a pregnant client. The client asks how the doctor could tell she was pregnant 'just by looking inside.' The nurse tells her the most likely explanation is that she had a positive Chadwick's sign, which is a A Bluish coloration of the cervix and vaginal walls B. Pronounced softening of the cervix C Clot of very thick mucous that obstructs the cervical canal D Slight rotation of the uterus to the right
Chadwick's sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.
The home care nurse is visiting an older female client whose husband died 6 months ago. Which behavior, by the client, indicates ineffective coping? Visiting her husband's grave once a month Participating in a senior citizens program Looking at old snapshots of her family Neglecting her personal grooming
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual physically or psychologically. Option D is indicative of a behavior that identifies an ineffective coping behavior in the grieving process.
A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the following nursing interventions is most appropriate to facilitate normal growth and development? A. Allow the family to bring in the child's favorite computer games B .Encourage the parents to room-in with the child C. Encourage the child to rest and read D.Allow the child to participate in activities with other individuals in the same age group when the condition permits
D Question 1 Explanation: Adolescents often are not sure whether 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 members of the peer group will support their ill friend. Options a, b, and c isolate the child from the peer group.
While teaching a 10 year-old child about their impending heart surgery, the nurse should A Provide a verbal explanation just prior to the surgery B Provide the child with a booklet to read about the surgery C Introduce the child to another child who had heart surgery three days ago D Explain the surgery using a model of the heart
D According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery.
The nurse's FIRST step in nutritional counseling/teaching for a pregnant woman is to A Teach her how to meet the needs of self and her family B Explain the changes in diet necessary for pregnant women C Question her understanding and use of the food pyramid D Conduct a diet history to determine her normal eating routines
D Assessment is always the first step in planning teaching for any client.
A pregnant woman is advised to alter her diet during pregnancy by increasing her protein and Vitamin C to meet the needs of the growing fetus. Which diet BEST meets the client's needs? A Scrambled egg, hash browned potatoes, half-glass of buttermilk, large nectarine B 3oz. chicken, ½ C. corn, lettuce salad, small banana C 1 C. macaroni, ¾ C. peas, glass whole milk, medium pear D Beef, ½ C. lima beans, glass of skim milk, ¾ C. strawberries
D Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good source of Vitamin C.
The nurse is observing children playing in the hospital playroom. She would expect to see 4 year-old children playing A Competitive board games with older children B With their own toys along side with other children C Alone with hand held computer games D Cooperatively with other preschoolers
D Cooperative play is typical of the preschool period.
Which statement regarding heart sounds is correct? a. S1 and S2 sound equally loud over the entire cardiac area. b. S1 and S2 sound fainter at the apex c. S1 and S2 sound fainter at the base d. S1 is loudest at the apex, and S2 is loudest at the base
D. The S1 sound—the "lub" sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the "dub" sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
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? Gardening every day for an hour Cycling 3 times a week for 20 minutes Sculpting once a week for 40 minutes Walking 3 to 5 times a week for 30 minutes
Exercise and activity are essential for health promotion and maintenance in the older adult and to achieve an optimal level of functioning. About half of the physical deterioration of the older client is caused by disuse rather that by the aging process or disease. One of the best exercises for an older adult is walking, progressing to 30 minutes session 3 to 5 times each week. Swimming and dancing are also beneficial.
Which is a major concern when providing drug therapy for older adults? Alcohol is used by older adults to cope with the multiple problems of aging Hepatic clearance is reduced in older adults Older adults have difficulty in swallowing large tablets Older adults may chew on tablets instead of swallowing them.
Hepatic clearance is reduced in older adults
The nurse is evaluating a new mother feeding her newborn. Which observation indicates the mother understands proper feeding methods for her newborn? A Holding the bottle so the nipple is always filled with formula. B Allowing her seven - pound baby to sleep after taking 1 ½ ounces from the bottle. C Burping the baby every ten minutes during the feeding. D Warming the formula bottle in the microwave for 15 seconds and giving it directly to the baby.
Holding the bottle so the nipple is always filled with formula prevents the baby from sucking air. Sucking air can cause gastric distention and intestinal gas pains. A seven-pound baby should be getting 50 calories per pound: 350 calories per day. Standardized formulas have 20 calories per ounce. This seven-pound baby needs 17.5 ounces per day. 17.5 ounces per day divided by 6-8 feedings equals 2-3 ounces per feeding. A normal newborn without feeding problems could be burped halfway through the feeding and again at the end. If burping needs to be at intervals, it should be done by ounces or half ounces, not minutes. Microwaving is not recommended as a method of warming due to the uneven heating of the formula. If used, the formula should be shaken after warming and the temperature then checked with a drop on the wrist. The recommended method of warming is to place the bottle in a pan of hot water to warm, and then check the temperature on the wrist before feeding.
A 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 of the following is the most appropriate activity for this child? Large picture books A radio Crayons and coloring book A sports video
In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. Large picture books are most appropriate for the infant. A radio and a sports video are most appropriate for the adolescent.
The nurse is caring for an agitated older client with Alzheimer's disease. Which nursing intervention most likely would calm the client? Playing a radio Turning the lights out Putting an arm around the client's waist Encouraging group participation
Nursing interventions for the client with Alzheimer's disease who is angry, frustrated, or hostile include decreasing environmental stimuli, approaching the client calmly and with assurance, not demanding anything from the client, and distracting the client. For the nurse to reach out, touch, hold a hand, put an arm around the waist, or in some way maintain physical contact is important. Playing a radio may increase stimuli, and turning the lights out may produce more agitation. The client with Alzheimer's disease would not be a candidate for group work if the client is agitated
The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. The BEST response is to tell her that the test A Measures potential intelligence B Assesses a child's development C Evaluates psychological responses D Diagnoses specific problems
The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test
The nurse is assessing a four month-old infant. The nurse would anticipate finding that the infant would be able to A Hold a rattle B Bang two blocks C Drink from a cup D Wave "bye-bye"
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate intervention? tell the friends to visit the child encourage patient to help child learn lessons missed call the priest to intervene tell the child's girlfriend to visit the child.
The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION. The most significant persons in this group are the PEERS. B refers to children in the school age while C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child is not dying and the situation did not even talk about the child's belief therefore, calling the priest is unnecessary.
When caring for an elderly client it is important to keep in mind the changes in color vision that may occur. What colors are apt to be most difficult for the elderly to distinguish? A Red and blue. B Blue and gold. C Red and green. D Blue and green.
The elderly are better able to distinguish between red and blue because of the difference in wavelengths. The elderly are better able to distinguish between blue and gold because of the difference in wavelengths. The elderly are better able to distinguish between red and green because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age. The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age.
While giving nursing care to a hospitalized adolescent, the nurse should be aware that the MAJOR threat felt by the hospitalized adolescent is A Pain management B Restricted physical activity C Altered body image D Separation from family
The hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance.
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. The nurse interprets this behavior as indicating that: The child is withdrawn The child is self-centered The child has adjusted to the hospitalized setting This is a normal pattern
The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In the stage of protest, when the parents return, the child readily goes to them. In the stage of despair, the child may not approach them readily or may cling to a parent. In denial or detachment, when the parents return, the child becomes cheerful, interested in the environment and new persons (seemingly unaware of the lost parents), friendly with the staff, and interested in developing superficial relationships.
The mother of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. The best nursing response is which of the following? When the toddler weighs 20 lbs The seat should not be placed in a face-forward position unless there are safety locks in the car The seat should never be place in a face-forward position because the risk of the child unbuckling the harness When the weight of the toddler is greater than 40 lbs
The transition point for switching to the forward facing position is defined by the manufacturer of the convertible car safety seat but is generally at a bodyweight of 9 kg or 20 lb and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb. Options b, c, and d are incorrect
The nurse is providing an educational session to new employees, and the topic is abuse to the older client. The nurse tells the employees that which client is most characteristic of a victim of abuse A 90-year-old woman with advanced Parkinson's disease A 68-year-old man with newly diagnosed cataracts A 70-year-old woman with early diagnosed Lyme's disease A 74-year-old man with moderate hypertension
The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits the ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.
Which age group has the greatest potential to demonstrate regression when they are sick? Adolescent Young Adult Toddler Infant
Toddler
A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes for eight hours and is 4 cm dilated. Since she is a candidate for infection, the nurse should include which of the following in the care plan? A Universal precautions. B Oxytocin administration. C Frequent temperature monitoring. D More frequent vaginal examinations
Universal precautions are necessary for all clients but a specific assessment of the client's temperature will give an indication the client is becoming infected. Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially. Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections, since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and uterine cavity. More frequent vaginal examinations are not recommended, as frequent vaginal exams can increase chances of infection.
A clinic nurse assesses the communication patterns of a 5-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant: Uses simple words such as "mama" Uses monosyllabic babbling Links syllables together Coos when comforted
Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as "mama" occurs between 9 and 12 months. Linking syllables together when communicating occurs between 6 and 9 months. Cooing begins at birth and continues until 2 months.
Which intervention is an example of primary prevention? a. Administering digoxin (Lanoxicaps) to a patient with heart failure b. Administering a measles, mumps, and rubella immunization to an infant c. Obtaining a Papanicolaou smear to screen for cervical cancer d. Using occupational therapy to help a patient cope with arthritis
nswer B. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.