ATI Nursing Throughout the Lifespan

A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for sever chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? A. Cholesterol screening B. Nutrition presentation C. Medication therapy D. Cardiac rehabilitation

A. A cholesterol screening is an example of secondary prevention B. CORRECT: Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness C. Starting medication therapy to lower cholesterol is an example of secondary prevention D. Starting cardiac rehabilitation is an example of tertiary prevention

A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning B. Select instructional materials appropriate for the older adult C. Identify goals the nurse and the client agree are reasonable D. Determine what the client knows about stress incontinence

A. Active participation in the learning process is essential for the success of the session. However, this is not the priority action B. It is essential for the nurse to prepare and select instructional materials appropriate for the client's age, developmental level, and other parameters. However, this is not the priority action C. Establishing mutually agreeable goals is essential for the success of the session. However, this is not the priority action D. CORRECT: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine how much the client knows about stress incontinence, the accuracy of this knowledge, and what the client needs to learn to manage this problem before instructing the client

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply) A. Install bath rails and grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home

A. Although bath rails and grab bars add a measure of safety to bathing activities, this recommendation addresses health risks common to the older adult population due to their risk for falls B. CORRECT: The nurse should encourage the client to wear a helmet while skiing to reduce the risk of head injury. Although it applies to other age groups, many young adults engage in winter sports. Therefore, this is an age-appropriate recommendation for this developmental group C. CORRECT: The nurse should remind the client to install a carbon monoxide detector in the home. This is an essential safety precaution for young adults as well as for all other developmental stages D. CORRECT: The nurse should warn the client to secure firearms in a safe location to reduce the risk of accidental gunshot injuries. Although it applies to all age groups, many young adults own firearms, so this is an age appropriate recommendation for this developmental group E. Although throw rugs can pose a safety hazard, this recommendation addresses health risks common to the older adult population due to their risk for falls

A nurse in a provider's office is collecting data from the mother of a 12-month-old infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic

A. An example of cognitive learning is stating the behavior the child will demonstrate when ready to toilet train B. CORRECT: Affective learning has taken place because the client's ideas about toilet training changed C. An example of psychomotor learning is performing the proper techniques for introducing the child to toilet training D. Kinesthetic learning is a learning style, not a domain of learning

A nurse is observing a client drawing up and missing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique B. The client is able to demonstrate the appropriate technique C. The client states that he understands D. The client is able to write the steps on a piece of paper

A. Discussing the appropriate technique demonstrates learning, but it does not involve the use of motor skills B. CORRECT: Demonstrating the appropriate technique indicates that psychomotor learning has taken place C. Verbalizing understanding demonstrates learning but it does not involve the use of motor skills D. Writing steps on paper demonstrates learning, but it does not involve the motor skills essential for performing the procedure

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

A. The HPV vaccine is recommended for female clients from age 11 to 26 and male clients from age 9 to 26. It is not a recommendation for older adults B. CORRECT: The pneumococcal vaccine is recommended for older adult clients C. CORRECT: A yearly eye examination to screen for glaucoma and vision changes is recommended for older adults D. CORRECT: Periodic mental health assessments are recommended for older adult clients to screen for depression E. CORRECT: An annual fecal occult blood test is recommended for older adults

A nurse is explaining to the parents of a 4-month-old infant what infant milestones to expect during the first year of life, and how to foster infant development. Cognitive Development: -Name the developmental stage Piaget has identified for the first two years of life -Identify three essential components that comprise this stage

Cognitive Development -Piaget's sensorimotor stage (first 2 years) Essential components of Sensorimotor -Separation -Object permanence -Mental representation

A nurse is explaining to a group of parents in a community center what cognitive development characteristics they should expect of their school-age children. Cognitive Development: List at least eight cognitive and language development expectations during young adulthood

Cognitive Development: -See weight and volume as unchanging -Understand simple analogies and relationships between things and ideas -Understand time (days, seasons) -Classify more complex information -Understand various emotions people experience -Become self-motivated -Solve problems and understand cause and effect -Define many words and understands rules of grammar -Understand that a word can have multiple meanings

A nurse on a pediatric unit is reviewing with a group of newly licensed nurses the cognitive developmental milestones to expect from adolescent clients. Cognitive Development: List at least five cognitive development expectations during adolescence

Cognitive Development: -Think at an adult level -Think abstractly and deal with principles -Evaluate the quailty of their own thinking -Have a longer attention span -Are highly imaginative and idealistic -Make decisions through logical operations -Are future-oriented -Are capable of deductive reasoning -Understand how actions of an individual influence others

A nurse is explaining to the parents of a 14-month-old toddler what physical and cognitive development they can expect from now until their child is 3 years old. Cognitive Development: Describe at least three parameters the parents can expect to observe during the toddler stage

During toddler stage: object permanence, memories of events that relate to them, domestic mimicry (playing house), symobolization of objects and people, use of 400 words, use of two- to three-word phrases

A nurse in a community health center is explaining to a group of middle adults what moral and cognitive development characteristics they should expect at this stage of life. Cognitive Development: -List at least two moral development expectations during middle adulthood -List at least four cognitive development expectations during middle adulthood

Moral Development: -Spiritual beliefs and religion can take on added importance -Middle adults can become more secure in their convictions -Middle adults often have advanced moral development Cognitive Development: -Reaction time and speed of performance slow slightly -Memory is intact -Crystallized intelligence remains (stored knowledge) -Fluid intelligence (how to learn and process new information) declines slightly

A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understand of safety for the infant? A. "My baby loved to play with his crib gym, but I took it away from him" B. "I just bought a soft mattress so my baby will sleep better" C. "My baby really likes sleeping on the fluffy pillow we just got for him" D. "I put the baby's car seat out of the way on the table after I put him in it"

A. CORRECT: Parents should remove gyms and mobiles at 4 to 5 months of age to prevent injury can occur from choking or strangulation B. The nurse should remind the parents the infant's crib mattress should be firm and fit tightly to prevent suffocation C. The nurse should remind the parents to remove pillows or stuffed animals from the crib to prevent possible suffocation D. The nurse should remind the parents to place the infant seat on the ground level when not in a vehicle to prevent falls

A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply) A. Assembling puzzles B. Pulling wheeled toys C. Using musical toys D. Playing with puppets E. Coloring with crayons

A. CORRECT: Putting puzzles together helps a preschooler develop fine motor and cognitive skills B. Pulling or pushing toys helps toddlers develop large muscles and coordination C. CORRECT: Playing with musical toys helps a preschooler develop fine motor skills and coordination D. CORRECT: Playing with puppets helps a presechooler develop oral language and actively use his imagination E. CORRECT: Using crayons to color on paper or in coloring books helps a preschooler develop fine motor skills and coordination

A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply) A. Influenza B. Measles, mumps, rubella C. Pertussis D. Tetanus E. Polio

A. CORRECT: The CDC recommends annual influenza immunization during adulthood B. The CDC recommends obtaining the measles, mumps, and rubella vaccines routinely during childhood. The series can be administered during adulthood for individuals who meet certain criteria C. CORRECT: The CDC recommends a booster dose of pertussis vaccine during adulthood D. CORRECT: The CDC recommends ongoing booster doses of tetanus and diphtheria vaccines during adulthood E. The CDC recommends the polio vaccine to be administered routinely during childhood. The series can be administered during adulthood for individuals who meet certain criteria

A nurse is assessing from a 2-week-old newborn during a routine checkup. Which of the following findings should the nurse expect? A. Sleeps 14 to 16 hr each day B. Posterior fontanel closed C. Pincer grasp present D. Hands remain in a closed position E. Current weight same as birth weight

A. CORRECT: The nurse should expect the newborn to sleep about 15 hr each day B. The nurse should expect the posterior fontanel to close around 2 to 3 months of age C. The nurse should expect the pincer grasp to develop around 8 months of age D. CORRECT: The nurse should expect the newborn to keep hands in a closed position until about 2 months of life E. CORRECT: The nurse should expect the newborn to have lost 5% to 10% of birth weight in the first few days of life, and regain the weight by the second week of life

A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? A. Establish consistent boundaries for the toddler B. Place the toddler in a room with the door closed C. Inform the toddler how you feel when he misbehaves D. Use favorite snacks to reward the toddler

A. CORRECT: Toddlers need consistent boundaries for discipline to be effective B. Placing a toddler in a room with the door closed can cause anxiety and fear C. A toddler is unable to understand how another person is feeling D. Using favorite foods as rewards can promote unhealthy eating habits

A nurse is talking with the parent of a 4-year-old child who stares that his child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? A. Offer the child a large snack before bedtime B. Allow the child to watch an extra 30 min of TV in the evening C. Have the child take an afternoon nap D. Increase physical activity before bedtime

A. Eating a large snack, especially one that is heavy or has a high sugar content, is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares B. Watching TV is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares C. CORRECT: The nurse should encourage the parent to have the child take an afternoon nap and to empty her bladder before bedtime to alleviate nightmares and night terrors D. Increasing physical activity is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares

A nurse at a community center is teaching a group of young adults what physical and cognitive development characteristics they should expect at this stage of life. Physical Development: List at least five physical development expectations Cognitive Development: List at least three cognitive development expectations during young adulthood

Physical Development: -Completion of growth -Peak in physical senses -Peak in cardiac output, efficiency -Optimal muscle function -Gradual decline in metabolic rate -High libido (men) -Eventual peak in libido (women) -Optimal childbearing -Pregnancy-related changes Cognitive Development: -Improvement in critical thinking -Peak in memory -Increased ability for creative thought -Relevance of values/norms of friends

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. "I am struggling to accept that my parents are aging and need so much help" B. "It's been so stressful for me to think about having intimate relationships" C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish" D. "I love my grandchildren, but my son expects me to relive my parenting days"

A. Adjusting to and caring for aging parents is nonurgent because it is an expected challenge during middle adulthood. There is another statement that the nurse should identify as the priority B. CORRECT: When using the urgent vs nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, developing intimacy vs isolation is a task of young adulthood. This middle adult is still struggling with this task and needs assistance in working through searching for and developing intimate relationships with others. C. Contributing to the community is nonurgent is nonurgent because it is an expected challenge during middle adulthood. There is another statement that the nurse should identify as the priority D. Questioning the ability to contribute to future generations is nonurgent because it is an expected challenge during middle adulthood. There is another statement that the nurse should identify as the priority

A nurse is evaluating teaching about nutrition with the parents of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? A. "She wants to eat as much as we do, but we're afraid she'll soon be overweight" B. "She skips lunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner" C. "We limit fast-food restaurant meals to three times a week now" D. "We reward her school achievements with a point system instead of a pizza or ice cream"

A. By the end of the school-age stage, parents should expect children to eat adult-size portions of food B. Skipping meals can lead to unhealthful snacking and overeating later in the day C. Parents should avoid fast-food restaurants completely to keep children from eating food high in sugar, fat, and starches D. CORRECT: Parents should avoid rewarding children with food for good behavior or achievements. Associations between food and feeling good can lead to weight problems

A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply) A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Playing board games

A. CORRECT: Building simple models helps the school-age child develop fine motor and cognitive skills B. CORRECT: Playing video games, especially educational and nonviolent ones, helps school-age children develop fine motor and cognitive skills C. CORRECT: Reading books helps the school-age child develop cognitive and fine motor skills D. Using toy carpentry tools helps preschoolers develop imagination and fine motor skills E. CORRECT: Playing board games builds cognitive skills and promotes social interaction

A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply) A. Suggest that his parents bring in video games for him to play B. Provide a television and DVDs for the adolescent to watch C. Limit visitors to the adolescent's immediate family D. Involve the adolescent in treatment decisions when possible E. Allow the adolescent to perform his own morning care

A. CORRECT: Nonviolent video games are suitable diversional activities for an adolescent B. CORRECT: Nonviolent DVDs are suitable diversional activities for an adolescent C. An adolescent client forms a strong attachment to peers. Allowing friends to visit should reduce the adolescent's feelings of isolation D. CORRECT: The adolscent is capable of thiniing through problems. Involving the adolsecent in decisions helps promote independence and control E. CORRECT: Allowing the adolescent to perform his own morning care helps promote a sense of independence and shows respect for his privacy

A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply) A. Obtain a periodic mental status evaluation B. Discuss prevention of sexually transmitted infections C. Regularly screen for tuberculosis D. Provide education about drug and alcohol use E. Teach monthly breast examinations for girls

A. CORRECT: Obtain an occasional mental status evaluation is important for the adolescent to reduce the risk for suicide, eating disorders, or substance use disorder B. CORRECT: Discuss prevention of sexually transmitted infections is important for the adolescent to reduce the risk for developing a sexually transmitted disease C. CORRECT: Periodically screen for tuberculosis is important for the adolescent to reduce the risk for developing or spreading tuberculosis D. CORRECT: Providing education about drug and alcohol use is important for the adolescent to reduce the risk for the use of alcohol and recreational drugs E. Young adult women should begin monthly breast examinations to screen for early breast cancer

A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply) A. Increase protein intake to increase muscle mass B. Decrease fluid intake to prevent urinary incontinence C. Increase calcium intake to prevent osteoporosis D. Limit sodium intake to prevent edema E. Increase fiber intake to prevent constipation

A. CORRECT: Older adults should increase protein intake to increase muscle mass and improve wound healing B. Older adults should increase fluid intake to prevent dehydration and constipation C. CORRECT: Older adults should increase calcium intake to reduce the risk for osteoporosis D. CORRECT: Older adults should limit sodium intake to reduce the risk for edema and hypertension E. CORRECT: Older adults should increase fiber to prevent constipation

A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply) A. Store toxic agents in locked cabinets B. Keep toilet seats up C. Turn pot handles toward the back of the stove D. Place safety gates across stairways E. Make sure balloons are full inflated

A. CORRECT: Parents must prevent toddlers from accessing dangerous substances B. Easy access to the water in the toilet bowl could result in aspiration or drowning C. CORRECT: Turn pot handles toward the back of the stove to prevent the toddler from reaching and pulling its contents down on themselves D. CORRECT: Safety gates at the bottom of a staircase prevent toddlers from climbing stairs and falling backward. Safety gates placed at the top of a staircase prevent toddlers from falling down the stairs E. Toddlers should not have access to balloons. Balloons can easily burst and toddlers can put fragments of the balloon or the entire deflated balloon in their mouth and asphyxiate

A nurse is planning a health promotion and primary prevention class for the parents of school-age children. Which of the following information should the nurse include? (Select all that apply) A. Provide information about the risk of childhood obesity B. Discuss the danger of substance use disorders C. Promote discussion about sexual issues D. Recommend the school-age child sit in the front seat of the car E. Reinforce stranger awareness

A. CORRECT: Parents of school-age children need to be aware of nutritional strategies for preventing childhood obesity B. CORRECT: Parents of school-age children need to know how to teach children to say no to illegal drugs, alcohol, and all other harmful or addictive substances C. CORRECT: Parents should discuss sexual issues with school-age children to promote healthy behavior D. The nurse should instruct the parents of school-age children to keep children under 13 years in the back seat of the car to reduce the risk of injury E. CORRECT: Parents should reinforce stranger safety as soon as their children are old enough to understand it, and throughout all stages of childhood

A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

A. CORRECT: Starting at age 20, the client should have examinations for testicular cancer, along with blood pressure and body mass index measurements and cholesterol determinations B. Blood glucose testing begins at age 45 C. Testing for fecal occult blood usually beings at age 50 D. Testing for prostate-specific antigen usually begins at age 50

A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply) A. Rolls from back to front B. Bears weight on legs C. Walks holding onto furniture D. Sits unsupported E. Sits down from a standing position

A. CORRECT: The infant should be able to roll from back to front by 6 months B. CORRECT: The infant should be able to bear weight on legs by 7 months C. The infant should be able to walk while holding furniture until around 11 months D. CORRECT: The infant should be able to sit unsupported by 8 months E. The infant should be able to sit down from a standing position until around 12 months

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply) A. Help the client see the benefits of her actions B. Identify the client's support systems C. Suggest and recommend community resources D. Devise and set goals for the client E. Teach stress management strategies

A. CORRECT: The nurse should assist the client to recognize the benefits of her health-promoting actions while also overcoming barriers to implementing actions B. CORRECT: The nurse should collect information about who can help the client change unhealthful behaviors, and then suggest steps to have friends and family to become involved and supportive C. CORRECT: The nurse should promote the client's use of any available community or online resources that an help the client progress toward meeting set goals D. The nurse and the client should work together to devise and set mutually agreeable goals that are also realistic and achievable E. CORRECT: The nurse should teach that stress is a contributing factor to cardiovascular disease, as well as many other specific and systemic disorders

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretions D. Far vision E. Glomerular filtration

A. CORRECT: The nurse should expect metabolism to decline, causing weight gain during middle adulthood B. The nurse should expect a decline in the ability to hear high-pitched sounds during middle adulthood C. CORRECT: In middle adulthood, decreases in secretions of bicarbonate and gastric mucus being and persist into older age. This increases the risk of peptic ulcer disease D. The nurse should expect a decline in near vision (presbyopia) during middle adulthood E. CORRECT: Middle adults begin to lose nephron units, which results in a decline in glomerular filtration rates

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply) A. Eye examination every 1 to 3 years B. Decrease intake of calcium supplements C. DXA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders

A. CORRECT: The nurse should recommend middle adult clients have an eye examination every 1 to 3 years to screen for glaucoma and other disorders B. The nurse should recommend that middle adult clients, especially women, increase intake of vitamin D and calcium to prevent osteoporosis C. CORRECT: The nurse should recommend middle adult client have a DXA scan to screen for osteoporosis D. CORRECT: The nurse should recommend middle adult clients obtain adequate protein, and consume more fresh fruits, vegetables and whole grains E. CORRECT: The nurse should recommend screening for anxiety and depression during middle adulthood

A mother tells the nurse that her 2-year-old toddler has temper tantrums and says "no" every time the mother tries to help her get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development? A. Trying to increase her independence B. Developing a sense of trust C. Establishing a new identity D. Attempting to master a skill

A. CORRECT: Toddlers express a drive for independence by opposing the desires of those in authority and attempting to do everything themselves B. Developing trust is a developmental task for infants C. Establishing a new identity is the developmental task of an adolescent D. Mastering a skill is a developmental task of school-age children

A nurse is talking with parents of a 12-year-old child. Which of the following issues verbalized by the parents should the nurse identify as the priority? A. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping" B. "Our son keeps trying to find ways around our household rules. He always wants to make deals with us" C. "We think our son is trying too hard to excel in math just to get the top grades in his class" D. "Our son is always afraid the kids in school will laugh at him because he likes to sing"

A. CORRECT: When using the urgent vs nonurgent approach to client care, the priority issue is the delay in motor skills, which could indicate an illness and requires further investigation B. The failure to understand rules is nonurgent because it is common for school-age, children to fail to understand the reasoning behind many rules and to try and find ways around them C. The self-motivation to excel is nonurgent because it is common for school-age children, who are in the state Erikson describes as industry vs. inferiority, to strive to develop a sense of industry through advances in learning D. The fear of disapproval from peers is nonurgent because it is common for school-age children, who are in the stage Erikson describes as industry vs. inferiority, to face the challenge of acquiring new skills and achieving success socially

A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understand of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area" B. "It is important to schedule routine health care visits even if I am feeling well" C. "I will just go to an urgent care center for my routine medical care" D. "There's no reason to seek help if I am feeling stressed because it's just part of life"

A. For protection against a wide variety of communicable illnesses, the nurse should encourage adults to obtain CDC-recommended immunizations throughout the lifespan B. CORRECT: Despite being in relatively good health, young adult clients should plan to participate in routine screenings and health care visits C. Urgent care centers offer limited services, typically for acute injuries or problems that cannot wait until a primary care provider is available. The nurse should encourage clients to establish a relationship with a primary care provider to consult for nonurgent health problems D. Although it is true that stress is inevitable, chronic stress can lead to sever health alterations. Young adults who have stress that is recurrent or escalating should seek medical care

A nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following client statements should the nurse identify as the priority to assess further? A. "I have my own apartment now, but it's not easy living away from my parents" B. "It's been so stressful for me to even think about having my own family" C. "I don't even know who I am yet, and now I'm supposed to know what to do" D. "My girlfriend is pregnant, and I don't think I have what it takes to be a good father"

A. Living away from home and establishing independent living is nonurgent because it is an expected challenge during a young adulthood. There is another statement the nurse should identify as the priority B. Transitioning from being single to being a member of a new family is nonurgent because it is an expected challenge during young adulthood. There is another statement the nurse should identify as the priority C. CORRECT: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage. According to Erikson, it is as task of adolescence to develop identity vs role confusion. The nurse should recognize this young adult is still struggling with this task and needs assistance in working through that dilemma D. Considering childbearing and parenting is nonurgent because it is an expected challenge during young adulthood. There is another statement the nurse should identify as the priority

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

A. Physiological changes that occur with aging can include decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which can cause wrinkles and dry, thin, transparent skin B. CORRECT: Physiological changes that occur with aging can include loss in height due to the thinning of intervertebral disks C. Physiological changes that occur with aging can include decreased saliva production, making xerostomia (dry mouth) a common problem D. CORRECT: Physiological changes that occur with aging can include thickening of the nails of the fingers and toes E. CORRECT: Physiological changes that occur with aging can include a reduced bladder capacity. While young adults have bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL

A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? (Select all that apply) A. Reassure the child an injection will not hurt B. Mix oral medications in a large glass of milk C. Offer the child choices when possible D. Have the parents bring in a favorite toy from home E. Engage the child in pretend play with a toy medical kit

A. Telling the preschooler the injection will not hurt will cause the child to distrust the nurse B. Oral medication should be mixed in a small amount of fluid to increase the chance of the child taking the entire dosage C. Offer the child choices when possible gives the child some control and helps reduce the child's fears D. CORRECT: Having familiar and cherished objects nearby is therapeutic for children during their hospitalization and is useful as a distraction during uncomfortable procedures E. CORRECT: Pretend play helps children to determine the difference between reality and fantasy (imagined fears), especially with the assistance of the nurse during hospitalization

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the parents of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply) A. Haemophilus influenzae type B B. Varicella C. Polio D. Hepatitis A E. Seasonal influenza

A. The CDC recommends Haemophilus influenzae type B immunizations during infancy, but not generally beyond 18 months of age B. CORRECT: The CDC recommends a varicella (chickenpox) immunization during the preschool years C. CORRECT: The CDC recommends a polio immunization during the preschool years D. The CDC recommends hepatitis A immunizations during infancy, but not generally beyond 24 months of age E. CORRECT: The CDC recommends seasonal influenza immunizations during the preschool years

A nurse is reviewing the CDC's immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma viurs E. Seasonal influenza

A. The CDC recommends rotavirus immunizations during infancy and not generally beyond 8 months of age B. CORRECT: The CDC recommends varicella (Chickenpox) immunizations during adolescence C. The CDC recommends herpes zoster (shingles) immunizations during middle adulthood, typically one dose at age 60 or beyond D. CORRECT: The CDC recommends human papilloma virus (genital warts) immunizations during adolescence E. CORRECT: The CDC recommends seasonal influenza immunizations during adolescence

A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? A. "I kind of like this boy in my class, but he doesn't like me back" B. "I want to hang out with the kids in the science club, but the jocks pick on them" C. "I am so fat, I skip meals to try to lose weight" D. "My dad wants me to be a lawyer like him, but I just want to dance"

A. The client is at risk for developing an altered self-esteem due to rejection from his peers. However, another issue is at the priority. IT is common for adolescents, who are in the stage Erikson describes as identify vs role confusion, to face the challenge of forming peer relationships and dating relationships B. The client is at risk for developing an altered self-esteem due to rejection from his peers. However, another issue is the priority. IT is common for adolescents, who are in the stage Erikson describes as identify vs role confusion, to face the challenge of becoming part of a peer group and establishing a group identify C. CORRECT: The greatest risk to the client is injury due to an eating disorder. The priority issue is to provide counseling to promote body image and ensure proper nutrition D. The client is at risk for developing an altered self-identity due to pressure from a parent. However, another issue is the priority. IT is common for adolescents, who are in the stage Erikson describes as identity vs role confusion, to face the challenge of forming an identity that will lead to higher education and a career

A nurse is counseling an older adult who describes having difficulty dealing with several issues .Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back" B. "It's been so stressful for me to have to depend on my son to help around the house" C. "I just heard my friend Al died. That's the third one in 3 months" D. "I keep forgetting which medications I have taken during the day"

A. The client is at risk for social isolation and loss of independence because of retirement. However, another issue is the priority B. The client is at risk for loss of independence and reduced self-esteem due to dependence upon his son. However, another issue is the priority C. The client is at risk for social isolation due to the loss of a friend. However, another issue is the priority D. CORRECT: The greatest risk to this client is injury from overdosing or underdosing medications due to loss of short-term memory. The priority issue for the nurse is to assist the client to implement safe medication strategies. The nurse should assist the client to use a pill organizer to help him remember to take his medications and to keep a list of all current medications

A nurse is providing teaching for an older adult client who has lost 4.5kg (9.9 lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply) A. "Eat three large meals a day" B. "Eat your meals in front of the television" C. "Eat foods that are easy to eat, such as finger foods" D. "Invite family members to eat meals with you" E. "Exercise every day to increase appetite"

A. The client should eat small frequent meals to increase nutritional intake B. The client should avoid distractions during meals to increase nutritional intake C. CORRECT: The nurse should encourage the client to eat finger foods because finger foods are easier for the older adult client to eat D. CORRECT: The nurse should encourage the client to involve family members with meals. Socialization during meals promotes nutritional intake E. CORRECT: The nurse should encourage the client to exercise daily to increase appetite

A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions B. Ask the client to explain how to select or prepare meals C. Encourage the client to fill out an evaluation form D. Ask the client if she has resources for further instruction on this topic

A. The client stated that she understood the content, so she might not ask any questions that would help the nurse evaluate learning B. CORRECT: A useful strategy for evaluating learning is to ask the client to explain in her own words how she will implement what she learned C. An evaluation form usually gives the client a means of evaluating the teaching. It might not offer clues about what the client has learned D. The nurse should identify the client's resources early in the instructional process. At this point, the exploration of resources does not help the nurse evaluate the client's learning

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision" B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say"

A. The client's concern about her spouse seeing the incision could indicate anxiety or depression B. The client's request for pain medicine could indicate fear and anxiety C. CORRECT: Asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. The client's new diagnosis of cancer can cause anxiety, fear, or depression, all of which can interfere with the learning process D. The lack of privacy due to the presence of a roommate can be a barrier to learning

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "So I don't need the colon cancer procedure for another 2 or 3 years" B. "For now, I should continue to have a mammogram each year" C. "Because the doctor just did a Pap smear, I'll come back next year for another one" D. "I had my blood glucose test last year, so I won't need it again till next year"

A. The female client who has no specific family or personal history of colorectal cancer should begin screening of procedures at age 50 B. CORRECT: The female client who is between the ages of 40 and 50 should have a mammogram annually C. The female client who is between the ages of 30 and 65, with no family or personal history of cervical cancer, should have a Pap smear and human papilloma virus test every 5 years D. The client who is age 45 should have a blood glucose test at least every 3 years. Unless there is a specific family or personal history of diabetes mellitus, annual blood glucose determinations are not necessary

A nurse is talking with a parent who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as the priority? A. "My son mimics my husband getting dressed" B. "My son has temper tantrums every time we tell him to do something he doesn't want to do" C. "I think my son truly believes that his toys have personalities and talk to him" D. "I feel bad when I see my son trying to hard to button his shirt"

A. The identification of the son with his father through imitation is nonurgent because it is an expected response for a preschooler. IT is common for preschoolers to identify with the parent of the same sex and to mimic that parent's behavior B. CORRECT: When using the urgent vs. nonurgent approach to client care, the priority issue is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage of development. According to Erikson, it is a task of the toddler stage to develop autonomy vs shame and doubt. This preschooler is still acting out with negativism, which is a persistent negative response to requests, often manifested in tantrums. He is still struggling with this task and needs assistance in working through that stage C. The strong imagination of a preschooler is nonurgent because it is expected for preschoolers to have an active imagination as well as an imaginary friend. It is common for preschoolers to manifest misperceptions in thinking, such as animism (the belief that inanimate objects are alive) D. Attempting to master activities such as dressing themselves is nonurgent because it is an expected activity for a preschooler. It is common for preschoolers, who are in the stage Erikson describes as initiative vs guilt, to face the challenge of mastering activities they can perform independently, such as dressing themselves

A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply) A. Develop an acceptance of diminished strength and increased dependence on others B. Spend time focusing on improving job performance C. Welcome opportunities to be creative and productive D. Commit to finding friendship and companionship E. Become involved with community issues and activities

A. The nurse should identify acceptance of diminished strength and increased dependence as a developmental task for older adulthood. B. CORRECT: Psychosocially healthy middle adults strive to do well in their environment as part of achieving Erikson's stage of generativity vs stagnation C. CORRECT: Psychosocially healthy middle adults accept life's opportunities for creativity and productivity and use these opportunities for achieving Erikson's stage of generativity vs stagnation D. The nurse should identify seeking and forming friendships as a developmental task of young adulthood E. CORRECT: Psychosocially healthy middle adults work to contribute to future generations through community involvement and parenting as part of achieving Erikson's stage of generativity vs stagnation

A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" between being responsible for two generations

A. The nurse should identify active involvement in the next generation as a developmental risk for middle adults B. The nurse should identify adjusting to major role changes associated with loss as a developmental task for older adults C. CORRECT: The nurse should identify exploring career options and then establishing oneself in a specific occupation as a major developmental task for a young adult D. The nurse should identify assuming responsibility for the previous as well as the next generation as a developmental task for middle adults

A nurse is teaching the father of a 12-year-old boy about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae C. Enlargement of the testes and scrotum D. Deepening of the voice

A. The nurse should identify emerging facial hair is a pubescent change. However, evidence-based practice indicates that another change occurs first B. The nurse should identify hair growth in nongential areas is a pubescent change. However, evidence-based practice indicates that another change occurs first C. CORRECT: Using evidence-based practice, the first prepubescent change in boys is an increase in the size of the testicles and scrotum, and growth of pubic hair D. The nurse should identify changing vocal quality is a pubescent change. however, evidence-based practice indicates that another change occurs first

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates his behavior after a social interaction B. The client states he is learning to trust others C. The client wishes to find meaningful friendships D. The client expresses concerns about the next generation

A. The nurse should identify evaluating behavior after a social interaction as a developmental task that begins during the preschool years B. The nurse should identify learning to trust others as a developmental tack of infancy during Erickson's trust vs mistrust stage C. The nurse should identify finding meaningful friendships as a developmental task for school age children D. CORRECT: Erickson's task for a middle adult as generativity vs. stagnation. The nurse should include showing concern for the next generation as an example for this age group

A nurse is reviewing car seat safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include? A. Use a car seat that has a three-point harness system B. Position the car seat so that the infant is rear-facing C. Secure the car seat in the front passenger seat of the vehicle D. Convert to a booster seat after 12 months

A. The nurse should instruct the parents to provide a car seat with a five-point harness system B. CORRECT: The nurse should instruct the parents to position the infant car seat in a rear-facing position in the center of the vehicle seat, when possible C. The nurse should instruct the parent to place the infant car seat in the back seat to reduce the risk for injury in the event of a crash D. The nurse should instruct the parents to continue using an infant seat until the child reaches age 2, or meets the height and weight limits for the seat

A nurse is caring for a 20-year-old client who is sexually active and has come to the college health clinic for a first-time checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? A. Measure vital signs B. Encourage HIV screening C. Determine risk factors D. Instruct the client to use condoms

A. The nurse should take vital signs when determining the client's need for health promotion and disease prevention. However, there is another action the nurse should take first. B. The nurse may suggest for the client to have a HIV screening when determining health promotion and disease prevention. However, there is another action the nurse should take first C. CORRECT: The first action the nurse should take using the nursing process is assessment. The nurse should talk with client first to determine what risk factors the client might have before initiating the appropriate health promotion and disease prevention measures D. The nurse may provide for the client and sue of condoms to decrease sexual health risk when determining the client's need for health promotion and disease prevention measures

The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? (Select all that apply) A. "It might be good to add bananas, as they can help with loose stools" B. "Let's make a list of the foods he is eating so we can spot any problems" C. "Did the changes begin after you started one particular food?" D. "Has he been vomiting since he started these new foods? E. "Most babies react with a little indigestion when you start new foods"

A. This response by the nurse suggests an intervention without first determining the cause of the infant's problem B. CORRECT: This response by the nurse is an attempt to to assess about the infant's diet to help determine whether a food allergy or intolerance is the cause of the diarrhea and fussiness C. CORRECT: This response by the nurse is an attempt to to assess about the infant's diet to help determine which food triggered the infant's behavior change. Parents should introduce one food at a time to help identify allergies or intolerances D. CORRECT: This response by the nurse is an attempt to assess for other changes caused by the infant's diet which could be linked to a food allergy or intolerance, such as vomiting, rash, or constipation E. This response by the nurse is nontherapeutic because it involves stereotyping, and offers false reassurance without any attempt to understand the infant's problem

A nurse is talking with the parents of a 10-year-old child who is concerned that their son is becoming secretive, such as closing the door when he showers, and dresses. Which of the following responses should the nurse make? A. "Perhaps you should try to find out what he is doing behind those closed doors" B. "Suggest that he leave the door ajar for his own safety" C. "At this age, children tend to become modest and value their privacy" D. "You should establish a disciplinary plan to stop this behavior"

A. This response implies that the child is doing something wrong B. A toddler requires constant supervision. This response suggests that the school-age child has something to fear in his own home, or that the child requires constant supervision C. CORRECT: School-age children develop a need for privacy. It is important for the parents to show trust in the child and respect the child's need for privacy D. This suggestion sounds like a punishment, and the parents have not presented any evidence that the child is doing anything wrong`

A nurse is planning on diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply) A. Building models B. Working with clay C. Filling and emptying containers D. Playing with blocks E. Looking at books

A. Toddlers are not cognitively or physically capable of building models. This play activity is acceptable for school-age children B. Toddlers put small objects into their mouths and can easily swallow bits of clay. This activity is unacceptable for a toddler C. CORRECT: This activity can help a toddler develop fine motor skills and coordination D. CORRECT: This activity can help a toddler develop fine motor skills E. CORRECT: This activity can help a toddler prepare to learn to read

A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? A. "I should keep feeding my son whole milk until he is 3 years old" B. "It's okay for me to give my son a cup of apple juice with each meal" C. "I'll give my son about 2 tablespoons of each food at mealtimes" D. "My son loves popcorn, and I know it's better for him than sweets"

A. When toddlers turn 2 years old, the parents should give them low-fat or fat-free milk, not whole milk. This reduces fat and cholesterol intake and helps prevent childhood obesity B. Toddlers should have 4 to 6 oz of juice per day. Juices do not have the whole fiber that fruit has, and they contain sugar, so parents should limit their use C. CORRECT: Serving sizes for toddlers should be about 1 tbsp of solid food per year of age, so 2-year-olds should have about 2 tbsp per serving D. Popcorn poses a choking hazard to toddlers

A nurse is explaining to the parents of a 4-month-old infant what infant milestones to expect during the first year of life, and how to foster infant development. Age-Appropriate Activities: -Identify at least two toys and two activities the nurse should suggest that the parents provider for their infant

Age-Appropriate Activities -Toys and activities -Rattles -Mobiles -Teething toys -Nesting toys -Playing pat-a-cake -Playing with balls -Reading books

A nurse is making safety recommendations to the parents of two preschoolers. Injury Prevention: List at least for key areas of safety and age-appropriate instructions for addressing each area

Bodily Harm: -Keep firearms in a locked cabinet or container -Teach stranger safety -Wear helmets when riding a bicycle or tricycle and during any other activities that increase head-injury risk -Wear protective equipment (helmet and pads) during physical activity -Remove doors from unused refrigerators or other equipment -Teach preschoolers not to walk in front of swings Burns: -Reduce the temperature setting on the water heater -Have smoke detectors in the home and replace the batteries regularly -Use sunscreen while outdoors -Teach preschoolers not to play with matches Drowning: -Do not leave children unattended in the bathtub -Closely supervise children at a pool or any other body of water -Teach children to swim Motor-Vehicle Injuries: -Use a forward-facing car seat with a harness in the back seat -If weight or height exceeds the forward-facing limit, use a belt-positioning booster seat Poisoning: -Avoid exposure to lead paint -Keep plants out of reach -Place safety locks on cabinets with cleaners and other chemicals -Keep a poison control number handy or program it into the phone -Keep medications in childproof containers out of reach -Have a carbon monoxide detector in the home

A nurse is preparing a presentation at a community center for a group of parents who want to learn how to prevent childhood obesity. Related Content: List at least three factors the nurse should consider when incorporating ways to enhance learning List at least three barriers the nurse might encounter among the attendees

Factors that enhance learning: -Perceived benefit -Cognitive and physical ability -Health and cultural beliefs -Active participation -Age -Educational level-appropriate methods Barriers to learning: -Fear -Anxiety -Depression -Physical discomfort -Pain -Fatigue -Environmental distractions -Health and cultural beliefs -Sensory and perceptual deficits -Psychomotor deficits

A nurse is reviewing safety precautions for older adults with a group of home health care assistive personnel. Injury Prevention: List at least 10 safety recommendations for older adults

Injury Prevention: -Install bath rails, grab bars, and handrails on stairways -Teach clients about safe medication use -Remove throw rugs -Eliminate clutter from walkways and hallways -Remove extension and phone cords from walkways and hallways -Instruct about how to use ambulation-assistive devices (walkers, canes) -Ensure adequate lighting -Remind clients to wear eyeglasses and hearing aids -Prevent substance use disorders -Avoid driving vehicles during or after drinking alcohol or taking substances that impair sensory and motor functions -Wear a seat belt when operating a vehicle -Wear a helmet while bike riding, skiing, and other recreational activities that increase head-injury risk -Install smoke and carbon monoxide detectors in the home -Secure firearms in a safe location

A nurse is explaining to the parents of a 14-month-old toddler what physical and cognitive development they can expect from now until their child is 3 years old. Physical Development: Identify at least four gross or fine motor skills the parents can expect at specific ages

Physical Development: -At 15 months, gross motor skills: walks without help, creeps up stairs -At 15 months, fine motor skills: uses cup well, builds tower of two blocks -At 18 months, gross motor skills: assumes standing position, jumps in place with both feet -At 18 months, fine motor skills: manages spoon without rotation, turns pages in book tow or three at a time -At 2 years, gross motor skills: walks up and down stairs -At 2 years, fine motor skills: builds a tower with six or seven blocks -At 2.5 years, gross motor skills: jumps with both feet, stands on one foot momentarily -At 2.5 years, fine motor skills: draws circles, has good hand-finger coordination

A nurse is caring for a client in a spinal cord injury rehabilitation center following head and neck injuries sustained while riding a bicycle. The client had surgery during the acute phase of treatment to relieve intracranial pressure and to stabilize his cervical spine. Now, the client and his partner are learning essential self-management strategies. Related Content: List each of the three levels of prevention with an example of each level from this client's history or from what this client might have done to prevent this injury and its life-altering consequences

Primary: Take various courses, read about bicycle safety (wear a helmet, use reflective accessories and lights for visibility to drivers, follow the rules of the road for the cyclists) Secondary: Emergency care, surgery Tertiary: Rehabilitative care, learning self-management procedures, strategies