NCLEX

A 9-year-old child is at the 98th percentile for weight and at the 40th percentile for height. What interpretation should the school nurse draw from this data? A) The child is overweight or large in stature. B) The child is experiencing a prepubescent growth spurt. C) The child is underweight or small in stature. D) The child is normal for size.

A Explanation: The NCHS growth charts use the 5th and 95th percentiles as criteria for determining those children who fall outside the normal limits for growth. Children whose height and weight are above the 95th percentile are considered overweight or large for stature. Prepubescent growth spurts are between ages 10 and 12 for girls and 12 and 14 for boys. This is not a normal proportion for height and weight for this 9-year-old.

A 4-year-old child is delayed in language skills. In developing a care plan, what would be the most appropriate nursing concept for the nurse to focus on for this child? A) Verbal communication B) Social isolation C) Parenting skills D) Auditory sensory perception

A Explanation: The best concept to focus on is the one that directly relates to the lack of language skills and gives the best guidance for appropriate nursing interventions. With this data, there is no evidence of hearing disability. There is insufficient data in the question to determine whether social isolation or parenting behaviors play a role in the language delay.

A mother has brought her 4-year-old child for Denver II testing for routine assessment of social and physical abilities. The child refuses to complete the testing. What should the nurse do? A) Reschedule the testing for another day. B) Explain that the child is developmentally delayed. C) Complete the test as scheduled. D) Refer the child to a specialist.

A Explanation: There is no evidence at this time that the child needs a specialist. The child's behavior does not indicate developmental delay. The child should not be forced to undergo testing that day. There are many reasons why a child would be uncooperative, including fatigue, illness, and fear. To get accurate results, the test should be rescheduled for another day.

The nurse is teaching an 8-year-old child about an upcoming procedure. What is the most appropriate nursing intervention considering the child's stage of growth and development? A) Provide visual aids, such as dolls, puppets, and diagrams in the explanation B) Provide a written pamphlet for the child to review prior to the procedure C) Discourage any display of emotional outbursts D) Request that the parents wait outside while the nurse provides instructions to the child

A Explanation: Visual aids such as dolls, puppets, and outlines of the body can be used to illustrate the cause and treatment of the child's illness. Use of such equipment provides information to the school-age child to help understand and cope with feelings about the procedure. Written pamphlets should be given to the parents to review prior to the procedure. Children should be allowed to cry or verbalize feelings without guilt as long as they hold still. Parents should be given a choice to accompany their child during the procedure.

The nurse is assessing a toddler client for an upper respiratory infection. The nurse suspects the child may have autism spectrum disorder​ (ASD). Which behavior caused the​ nurse's suspicion? A) Having a tantrum when touched by the nurse B) Crying after the administration of immunizations C) Speaking to the nurse in sentences D) Playing with the other children and toys while awaiting the nurse

A Rationale: An assessment finding that supports the diagnosis of ASD is having a tantrum when touched by the healthcare provider. It is not uncommon for the child with ASD to display an inability to attend and systematize situational reactions. Playing with other​ children, speaking to the nurse in​ sentences, and crying after the administration of immunizations are not findings that support ASD. These assessment findings are age appropriate for the client

The nurse is assessing clients at the community clinic. Which group does the nurse consider as appropriate for genetic testing for cystic fibrosis​ (CF) via blood or​ saliva? A) All couples expecting a baby B.) Couples, with a family history of​ CF, expecting a baby C) Those with no history of CF D) Only the parent with a family​ history, when expecting a baby

A Rationale: Genetic​ (or carrier) testing not only plays a key role in the diagnosis of cystic​ fibrosis, but testing also allows parents to find out what their chances of having a child with CF are to help inform important family planning decisions. It is recommended that all couples be tested for the possibility of CF.

The nurse is caring for an older adult client with geriatric failure to thrive​ (GFTT). Which direction should the nurse include in the discharge instructions for this​ client? A) Teach about the use of selective serotonin reuptake inhibitors​ (SSRIs) for depression. B) Eat larger meals 3 times per day. C) Provide foods recommended by the dietitian. D) Teach the family to prepare all the​ client's meals.

A Rationale: Older adult clients diagnosed with GFTT may require teaching about SSRIs as a treatment method if the FTT is caused by depression. The client should be instructed to eat more small meals each day and to choose foods that are enjoyed. The nurse should assess the​ client's ability to prepare meals instead of teaching the family that all meals must be prepared for the client. It is not appropriate for the nurse to provide the food at discharge

During a prenatal​ visit, a pregnant client admits to using cocaine at least once per​ day, and that getting cocaine is her highest priority. Which problem should the nurse make a priority for this​ client? A) Imbalanced​ Nutrition: Less than Body Requirements related to limited food intake B) Risk for Infection related to drug use C) Impaired Gas Exchange related to respiratory effects of substance abuse D) Activity Intolerance related to decreased tissue oxygenation

A ​Rationale: A person who abuses substances will spend money on drugs rather than food and other basic​ needs, which will lead to Imbalanced​ Nutrition: Less than Body Requirements related to limited food intake. Activity Intolerance related to decreased tissue oxygenation does not relate to cocaine use. Clients may have trouble sleeping or getting adequate rest from using cocaine. Risk for Infection related to drug use might be appropriate for cocaine​ use, but the question does not specify how cocaine is being used. Impaired Gas Exchange related to respiratory effects of substance abuse is inappropriate because it is a​ risk, not a current problem.​ (NANDA-I ©​ 2014)

The school nurse is helping to create an individualized education plan​ (IEP) for a young client with​ attention-deficit/hyperactivity disorder​ (ADHD). Which behavioral goal should the nurse include in the plan of​ care? A) The client will respect the boundaries of others. B) The client will demonstrate a decrease in attentiveness. C) The client will accurately manage medication administration. D) The client will achieve school performance to minimum competency.

A ​Rationale: An appropriate behavioral goal for the client with ADHD is respecting the boundaries of others. Because the client is a​ child, it is not appropriate to expect the client to manage medication administration. The client should demonstrate an​ increase, not​ decrease, in attentiveness. An appropriate goal is for the client to achieve school performance to maximum​ potential, not merely minimum competency

The home care nurse is visiting a child diagnosed with autism spectrum disorder​ (ASD). Which intervention is appropriate for the nurse to include in the treatment plan for this​ family? A) Providing appropriate education regarding what to expect for the child B) Recommending that the home be a​ therapy-free zone C) Encouraging the family to get over negative feelings regarding the diagnosis D) Focusing on the​ child's limitations

A ​Rationale: An appropriate intervention for the family of a child diagnosed with ASD is for the nurse to provide education about what to expect. The nurse would encourage the family to grieve the loss of the​ "perfect child" and encourage the parents to focus on the​ child's strengths and talents. In order for therapy to be​ effective, the nurse would recommend that treatments be continued at home.

The nurse is planning care for a client with failure to thrive​ (FTT). Which goal should the nurse identify for this​ client? A) Parental understanding of the​ child's nutritional requirements B) Parental understanding of the​ child's stress and coping C) Parental understanding of the​ child's trauma prevention D) Parental understanding of the​ child's safety

A ​Rationale: Attaining adequate growth and normal development of the​ child, improving the parent-child relationship and the parental understanding of the​ child's nutritional​ requirements, and preventing complications associated with poor nutrition should be the goals of nursing care for the child with FTT.​ Safety, stress and​ coping, and prevention of trauma are not appropriate goals for the client with FTT.

The nurse notes a high level of stress between the parents of a child with cerebral palsy​ (CP). Which action should the nurse take to support the​ parents? A) Listen to concerns and encourage expression of feelings B) Refer all medical questions to the healthcare provider C) Explain that all children with CP are eventually placed in​ long-term care facilities D) Make a referral for marriage counseling

A ​Rationale: Parents require emotional support to help them cope with the diagnosis. Listen to the​ parents' concerns and encourage them to express their feelings and ask questions. The nurse should encourage the family to ask questions and should obtain answers to questions that the nurse is unable to answer. All children with CP are not eventually transferred to a​ long-term care​ facility; many are successfully cared for at home. Referrals for individual and family counseling are​ appropriate, but the nurse is not qualified to suggest a referral for marriage counseling.

The nurse is teaching an older adult client with geriatric failure to thrive​ (GFTT) about nutritional supplementation. Which supplemental vitamin should the nurse include in this​ teaching? A) Vitamin D B) Vitamin A C) Vitamin C D) Vitamin E

A ​Rationale: Pharmacologic therapies for the treatment of GFTT typically involve vitamin regimens. Vitamin D is one of the most commonly prescribed supplements for GFTT clients. Vitamins​ A, C, and E are not nutritional supplements for GFTT.

The nurse is caring for a client who has cerebral palsy​ (CP). Which intervention should the nurse use to promote flexibility and prevent​ contractures? A) Perform​ range-of-motion (ROM) exercises B) Administer mood stabilizers C) Provide muscle relaxants D) Schedule speech therapy

A ​Rationale: ROM exercises promote flexibility and prevent contracture formation. Muscle​ relaxants, mood​ stabilizers, and speech therapy do not promote flexibility or prevent contractures.

An adult client recently diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD) asks about treatment options. Which treatment option should the nurse​ recommend? A) Requesting a nonstimulant medication from the healthcare provider B) Minimizing all changes in the home and work environment C) Having a​ loose, flexible schedule so that activities can be adjusted quickly D) Requesting a stimulant medication from the healthcare provider

A ​Rationale: The nonstimulant medication atomoxetine​ (Strattera) is approved for use in adults. Stimulant medications such as dexmethylphenidate​ (Focalin) are not approved for use in adults. Environmental modifications that decrease​ stimulation, such as maintaining a quiet environment and having an orderly work​ area, are beneficial to clients with ADHD. Having a structured routine is more helpful to clients with ADHD than a​ loose, flexible schedule.

The nurse is teaching the parents of a very young client newly diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD) about the newly prescribed medication methylphenidate​ (Ritalin). Which instruction should the nurse​ include? A) Give the medication first thing in the morning. B) Restrict the amount of calories that the client eats each day. C) Give the medication prior to going to bed at night. D) Observe the child for excessive sleepiness.

A ​Rationale: The parents should give the medication first thing in the morning to ensure attentiveness and alertness during the day at school. This medication should not be given at bedtime because it can cause insomnia. The client should be observed for​ insomnia, rather than excessive sleepiness.​ Lastly, the client should be encouraged to consume an adequate amount of calories because this medication can also cause anorexia.

Which intervention should improve​ self-feeding ability in a child with spasticity caused by cerebral palsy​ (CP)? A) Providing utensils with adaptive handles B) Presenting large portions of food all at one time C) Providing a​ low-fiber diet D) Restricting hydration

A ​Rationale: Utensils with adaptive handles may improve​ self-feeding ability in children with spasticity associated with CP. Other possible interventions include feeding small amounts of food at a time. Restricting fluids and a​ low-fiber diet will not improve​ self-feeding ability in this client.

The nurse is assessing a child at the​ 1-year well-child visit. The child is alert and calm but does not follow or reach for the toy the nurse is moving back and forth. This is a significant change from the​ child's 6-month visit. Which response by the​ nurse, to the​ parents, is most​ appropriate? A) "Let's have the healthcare provider complete an​ evaluation, then we can​ talk." B) "I wouldn't​ worry; it is close to the​ child's naptime and she is probably just​ tired." C) "This is concerning. You may want to think about physical therapy for your​ child." D) "Has the child hit her head or had any injuries since the last​ well-child visit?"

A ​Rationale: When there is a significant change from one well visit to the​ next, the nurse must be aware this requires an evaluation. Once the healthcare provider completes an​ assessment, the nurse can discuss any concerns with the parents and what steps should be taken. It is not appropriate to dismiss the change and attribute it to the child being tired. Asking if there has been a head injury is likely to frighten the parents unnecessarily. It is outside of the​ nurse's scope of practice to refer to physical therapy.

The nurse is identifying nursing diagnoses appropriate for an infant with failure to thrive​ (FTT). Which nursing diagnosis should the nurse eliminate from the plan of​ care? A) Activity, Increased B) Parenting, Impaired C) Nutrition, Imbalanced: Less than Body Requirements D) Development: Delayed, Risk for

A ​Rationale: ​Activity, Increased is not an appropriate nursing diagnosis for an infant diagnosed with FTT. ​Nutrition, Imbalanced: Less than Body​ Requirements; ​Development: Delayed, Risk​ for; and​ Parenting, Impaired are all appropriate nursing diagnoses for this health problem.​ (NANDA-I ©​ 2014)

The nurse assesses a child suspected of having autism spectrum disorder​ (ASD). Which behavior noted in the assessment supports the​ diagnosis? (Select all that​ apply.) A) Echolalia B) An aversion to being touched C) Stereotypy D) Deep set eyes E) Emotional calm

A, B, C ​Rationale: Behaviors indicative of ASD include stereotypy​ (rigid and obsessive​ behavior), echolalia​ (the compulsive parroting of a word or phrase just stated by​ another), and an aversion to being touched. Emotional lability​ (rapid, significant mood​ changes), not emotional​ calm, is a clinical manifestation of ASD. ASD does not manifest in any physical signs.

A new graduate nurse is caring for a stable client with cystic fibrosis​ (CF). Which intervention by the graduate nurse requires the nurse preceptor to​ intervene? (Select all that​ apply.) A) Providing constant oxygen B) Giving an​ over-the-counter cough suppressant C) Administering a prescribed bronchodilator after chest percussion D) Recommending a​ high-calorie diet

A, B, C ​Rationale: Clients with CF should not take cough suppressants because coughing is essential to airway clearance. Bronchodilators should be used before chest percussion​ therapy, not after. Clients with CF should be encouraged to eat a​ high-calorie diet. Oxygen is only recommended as prescribed.

The nurse admitting a child who is suspected of having autism spectrum disorder​ (ASD) knows that it is necessary to rule out medical causes for the​ child's behavior before diagnosing ASD. Which diagnostic test should the nurse anticipate will be ordered for the​ client? (Select all that​ apply.) A) CT scan B) Electroencephalography C) DNA analysis D) ABG E) KUB​ x-ray

A, B, C ​Rationale: To rule out medical causes for behavior in a suspected ASD​ client, the healthcare provider should order a CT scan or​ MRI, DNA​ analysis, lead​ screening, and electroencephalography. A KUB​ x-ray is a radiograph of the​ kidneys, ureters, and bladder. ABGs are arterial blood gases and are used to measure the amounts of oxygen and carbon dioxide in the blood. They are not used to rule out ASD.

The nurse is planning care for a client with failure to thrive​ (FTT). Which nonpharmacologic approach should the nurse consider for this​ client? (Select all that​ apply.) A) Assessing and educating a breastfeeding mother B) Detailed history and physical exam C) Nutritional supplements D) Hospitalization E) Removal from the home

A, B, C, D Rationale: Appropriate nonpharmacologic therapy includes nutritional​ supplements, assessing and educating a breastfeeding​ mother, hospitalization, and a detailed history and physical exam. Removal from the home is not appropriate treatment for FTT.

The nurse is addressing a group of​ high-risk teen mothers. Which risk factor that can lead to​ attention-deficit/hyperactivity disorder​ (ADHD) in teens should the nurse include in the​ discussion? (Select all that​ apply.) A) Exposure to high levels of lead in childhood B) Poor nutrition C) Drinking alcohol during pregnancy D) Lack of proper parenting E) Affluence

A, B, C, D Rationale: Risk factors for ADHD in teens include improper​ parenting, exposure to high levels of​ lead, prenatal exposure to​ alcohol, and poor nutrition. Poverty is an environmental risk​ factor, not affluence.

A parents group asks the nurse what they should look for if they suspect their​ school-age child has ​ attention-deficit/hyperactivity disorder​ (ADHD). Which observation should the nurse instruct the parents to report to their​ child's healthcare provider​ (HCP) for further​ assessment? (Select all that​ apply.) A) Inability to stay on an assigned task to completion B) Having difficulty with learning at school C) Limited attention span when speaking with parent D) Excessive motor activity E) Deliberately destroying other​ people's property

A, B, C, D Rationale: The required findings for a diagnosis of ADHD are limited attention​ span, an inability to stay on an assigned​ task, and excessive motor activity with the inability to sit still for more than a few minutes. Clients with ADHD are frequently labeled as poor achievers with difficulty learning. While many of the behaviors of ADHD in adolescence and adulthood could be considered​ antisocial, such as destruction of​ property, this type of behavior would be less likely to occur in a younger child. Both children and adolescents with ADHD sometimes struggle with making and maintaining friends.

A client requiring a mandatory​ court-ordered drug testing is seen in the clinic. On which body tissue should the nurse conduct this​ testing? (Select all that​ apply.) A) Saliva B) Hair C) Serum D) Urine E) DNA

A, B, C, D ​Rationale: Mandatory drug tests may be done with a variety of diagnostic​ procedures, including testing on​ urine, saliva,​ serum, and hair.​ Genetic/DNA testing is unrelated to drug use.

The nurse is teaching the parents of a child recently diagnosed with autism spectrum disorder​ (ASD). Which etiologies should the nurse​ include? (Select all that​ apply.) A) Environmental factors B) Neurotransmitters C) Immunologic factors D) Genetics E) Mercury-containing vaccinations

A, B, C, D ​Rationale: The etiology of ASD is​ uncertain, but it is believed to be the result of an intricate​ co-action between​ genetic, immunologic, and environmental circumstances. There is research being conducted on the role of​ neurotransmitters, such as dopamine and serotonin. There is no evidence that​ mercury-containing vaccinations cause autism.

The nurse is preparing teaching material about cerebral palsy​ (CP). Which nonpharmacologic therapy should the nurse include in this​ teaching? (Select all that​ apply.) A) Special education B) Speech therapy C) Physical therapy D) Oxygen therapy E) Occupational therapy

A, B, C, E Rationale: Clinical therapy is used for clients who have CP to help them develop their maximum level of independence. To improve motor function and​ ability, referrals are made for​ physical, occupational, and speech​ therapy, as well as special education. Oxygen therapy is not necessary for all individuals with​ CP, only those with breathing disorders who require

The nurse is preparing teaching for an adolescent client who has a newly prescribed medicine. Which​ factor/information should the nurse consider when providing information to the​ client? (Select all that​ apply.) A) Compliance requirements B) Possible side effects C) Physical development of the client D) Physical therapy requirements E) Cognitive level of the client

A, B, C, E Rationale: In addition to prescription instructions regarding compliance and side​ effects, it is important for the nurse to consider the physical and cognitive development of the client. Most adolescents have reached a stage in physical development that they may be able to take an adult dosage. The cognitive development of these clients is also very​ broad, and if necessary the nurse should enlist the help of the parent or guardian. Physical therapy requirements do not need to be a consideration at this time.

The parents of a child with cerebral palsy​ (CP) ask if there are any medications available to help control the​ child's symptoms. Which type of medication should the nurse discuss with the​ parents? (Select all that​ apply.) A) Baclofen B) Benzodiazepines C) Muscle relaxants D) Antidepressants E) Botulinum toxin

A, B, C, E Rationale: Medications that are used to control seizures and spasms include skeletal muscle​ relaxants, baclofen,​ benzodiazepines, and botulinum toxin. Antidepressants are not used to manage the symptoms of CP. Next Question

The nurse completes an assessment of an infant with failure to thrive​ (FTT). Which data should the nurse​ record? (Select all that​ apply.) A) Percentile on the standard growth chart B) Accurate measurement of height and weight C) Activity level D) Food preferences E) BMI

A, B, C, E ​Rationale: Assessment data specific for FTT include accurate measurement of height and​ weight, percentile on the growth​ chart, activity​ level, and current BMI. Food preferences should not be included for an infant diagnosed with FTT.

Which instruction should the nurse include when teaching the parents of a​ 3-year-old child with autism spectrum disorder​ (ASD)? (Select all that​ apply.) A) Establishing therapies to assist with building play skills B) Teaching problem solving regarding client issues C) Providing for play with other children of the same age D) Administering stimulants to calm repetitive motions E) Providing methods to decrease the incidence of head banging

A, B, C, E ​Rationale: Clients with ASD have behaviors that interfere with functioning and can be harmful to​ them, such as banging their head or hitting solid objects. Provide clients who have ASD with early physical and occupational therapy that may be beneficial in developing some play and social skills. Clients with ASD may keep themselves in​ isolation, and assisting the clients to be able to be in the presence of others is a focus of treatment. The client with autism spectrum disorder may not progress to living​ independently; therefore, parents need to learn​ problem-solving skills to assist them and the client throughout life. Stimulants are a​ pharmacologic, not​ nonpharmacologic, treatment for autism spectrum disorder.

The nurse is preparing teaching material for the parents of a child with cerebral palsy​ (CP). Which treatment should the nurse include in this​ teaching? (Select all that​ apply.) A) Serial casting B) Positioning devices C) Surgery D) A​ low-calorie diet E) Muscle relaxants

A, B, C, E ​Rationale: Muscle relaxants may help the child with spasticity often associated with CP. Surgery may be helpful for children who experience contractures as a result of CP. Serial casting may be helpful for children with CP. Positioning devices are used to prevent contractures. A​ low-calorie diet is not recommended for children with CP.

The nurse is assessing a​ high-functioning adult client who is diagnosed with autism spectrum disorder​ (ASD). Which characteristic of ASD should the nurse anticipate this client will demonstrate during the nursing​ assessment? (Select all that​ apply.) A) Choosing inappropriate topics to discuss B) Understanding body language C) Lacking the ability to participate in small talk D) Displaying problems with sentence structure E) Having trouble with double meanings

A, B, C, E ​Rationale: Socialization and​ communication, especially understanding nonverbal​ communication, are lifelong struggles for the adult with ASD. Behaviors that the nurse will anticipate during the assessment include choosing inappropriate topics to​ discuss, not engaging in small​ talk, understanding body​ language, and having trouble with double meanings. The nurse would not expect the adult client with ASD to display problems with sentence structure

Which intervention should the nurse include in the plan of care for a young client with​ attention-deficit/hyperactivity disorder​ (ADHD)? (Select all that​ apply.) A) Encouraging therapeutic play B) Using​ time-outs C) Varying consequences for negative behaviors D) Promoting​ self-esteem E) Increasing environmental stimulation

A, B, D Rationale: Encouraging therapeutic​ play, using​ time-outs, and promoting​ self-esteem are all appropriate nursing interventions for the young client with ADHD. Environmental stimulation should be​ minimized, not​ increased, and consequences for negative behaviors should be​ consistent, not varied.

The nurse evaluates teaching provided to a group of new parents on failure to thrive​ (FTT). Which statement should indicate to the nurse that teaching was​ effective? (Select all that​ apply.) A) "The majority of FTT cases are not related to a physical​ problem." B) "Misinterpreting hunger cues can lead to​ FTT." C) "Many people think all Asian children have​ FTT; the truth is they are just small and never get the​ disorder." D) ​"FTT can often be prevented by classes such as this​ one." E) "Breastfed babies never develop​ FTT."

A, B, D Rationale: FTT is often caused by misinterpreting hunger cues. The majority of FTT cases are not related to physical problems. FTT can often be prevented by educating the parents and caregiver. FTT can develop in any client. Breastfed babies can develop FTT.

The nurse is caring for a client with cerebral palsy​ (CP) who wears bilateral leg braces and requires full assistance to mobilize. For which condition is the client at​ risk? (Select all that​ apply.) A) Muscle contractures B) Pressure injuries C) Increased dental caries D) Fatigue E) Atherosclerosis

A, B, D Rationale: The nurse should protect bony prominences and assess regularly for redness and skin breakdown under the braces. The​ client's inability to change positions independently also places her at risk for pressure wounds and muscle contractures. Fatigue results from the extended energy needed to work against the muscle contractures. Atherosclerosis is a severe problem with CP that is associated with aging but is not caused by the leg braces or immobility. Dental caries are also unrelated to the braces or physical dependence. OK

The nurse is conducting a consultation with a client who has a developmental alteration. Which factor should the nurse consider when interacting with the​ client? (Select all that​ apply.) A) Developmental level B) Preferred learning method C) Family history D) Literacy skills E) Reliance on social services

A, B, D Rationale: When interacting with a client who has a developmental​ alteration, the nurse should consider the​ client's developmental​ level, literacy​ skills, and preferred learning method. The​ client's family history and reliance on social services are not related to interactions with the client.

Which is characteristic of​ attention-deficit/hyperactivity disorder​ (ADHD)? (Select all that​ apply.) A) Linked to heredity B) Often persists into adulthood C) Impulsivity persists in adults D) Linked to exposure to excess lead E) Acetylcholine deficit in some children

A, B, D ​Rationale: Attention-deficit/hyperactivity disorder​ (ADHD) is characterized by​ inattention, hyperactivity, and impulsivity. Exposure to excess lead can contribute to the development of ADHD. There is a strong link between heredity and the development of ADHD. Thirty to seventy percent of ADHD cases persist into adulthood. Hyperactivity and impulsivity often improve as the client gets​ older, with inattentiveness becoming the most persistent characteristic in adults. Some children with ADHD have a deficit in dopamine and​ norepinephrine, not acetylcholine.

The nurse is teaching about​ Piaget's theory of cognitive development. The nurse assesses that teaching has been effective when the nurses correctly identify which phase associated with​ Piaget's theory?​ (Select all that​ apply.) A) Sensorimotor phase B) Concrete operational phase C) Accommodation phase D) Preoperational phase E) Assimilation phase

A, B, D ​Rationale: Piaget's theory consists of the following​ phases: sensorimotor,​ preoperational, concrete​ operational, and formal operational phases. Assimilation and accommodation are abilities that an individual uses to progress through the phases of cognitive development.

The nurse is conducting an educational session for the staff about failure to thrive​ (FTT). Which type of family should the nurse identify as being at risk for this health​ problem? (Select all that​ apply.) A) Abuse substances B) History of depression C) Single-parent D) Low-income E) Experience mental retardation

A, B, D, E

The nurse prepares a teaching tool about substance abuse in older adults. Which information should the nurse​ include? (Select all that​ apply.) A) Alcohol and other substances can make it difficult to diagnose medical problems. B) Individuals can have substance abuse problems at any age. C) Substance abuse is more likely to be recognized in older adults. D) Older women are more likely to use prescription medicines. E) Depression and alcohol abuse are disorders frequently found in clients who completed suicide.

A, B, D, E Rationale: Individuals can have substance abuse problems at any age. Older women are more likely to use prescription medicines. Alcohol and other substances can make it difficult to diagnose medical problems. Depression and alcohol abuse are disorders frequently found in clients who completed suicides. Substance abuse is less likely to be recognized in older adults due to insufficient​ knowledge, lack of​ research, and hurried office visits.

A client is being treated for glue inhalation. Which independent intervention should the nurse expect to​ implement? (Select all that​ apply.) A) Assessing the​ client's heart​ rate, respirations, and blood pressure B) Maintaining a quiet environment C) Administering an opioid antagonist intravenously D) Assigning the client to one nurse for therapeutic intervention E) Maintaining an accurate record of fluid intake and output

A, B, D, E Rationale: Inhalants can displace oxygen and cause tachycardia and respiratory depression. Assess for renal function because chemicals found in many glues can cause chronic renal damage. It is best to have a single nurse who talks​ to, calms, and reassures the client until the effects of the substance use subside. To calm the​ client, external stimuli should be​ reduced, with minimal​ sound, light, and activity. An opioid antagonist is not effective with the use of inhalants.

The nurse suspects an infant has failure to thrive​ (FTT). For which reason should the nurse anticipate this client being​ hospitalized? (Select all that​ apply.) A) Teach the caregivers how to identify physiologic hunger cues B) Promote growth and development C) Protect the child from the caregivers D) Assist in establishing a feeding routine E) Provide adequate caloric and nutritional intake

A, B, D, E ​Rationale: A client with FTT does not necessarily need protection from the caregivers. The goal of treatment for a client with FTT is to promote growth and​ development, establish feeding and sleep​ patterns, provide adequate caloric and nutritional​ intake, and teach the caregivers how to recognize hunger cues.

During an​ assessment, the nurse suspects that an​ 18-month-old client is demonstrating manifestations of cerebral palsy​ (CP). Which assessment finding should the nurse use to validate this​ conclusion? (Select all that​ apply.) A) Arched back B) Poor trunk control C) Thumb sucking D) Asymmetric crawling E) Head lag

A, B, D, E ​Rationale: Abnormalities that can be assessed that indicate cerebral palsy include asymmetric​ crawling, head​ lag, arched​ back, and poor trunk control. Thumb sucking is not a manifestation of CP.

The nurse is assessing a client with a dependency on cocaine. Which cognitive manifestation should the nurse expect to assess in this​ client? (Select all that​ apply.) A) Expresses feelings of anxiety. B) Pulls at clothes while fidgeting in the chair. C) States sleeping all the time. D) Appears overly happy despite the hospital admission. E) Talks incessantly with rambling thought pattern

A, B, D, E ​Rationale: Individuals who routinely use cocaine have symptoms of​ anxiety; demonstrate excessive talking that indicates rambling thought​ processes, elation,​ euphoria, and sometimes tactile hallucinations.​ Insomnia, not excessive​ sleeping, occurs in those who routinely use cocaine.

The nurse is teaching a client who uses intravenous drugs about the potential for health problems. Which infectious bloodborne disease should the nurse include in this​ teaching? (Select all that​ apply.) A) HIV B) AIDS C) Tuberculosis D) Hepatitis B E) Hepatitis C

A, B, D, E ​Rationale: Intravenous​ (IV) drug use increases the exposure and transmission of certain infectious​ diseases, such as hepatitis B and​ C, and​ HIV/AIDS. Tuberculosis is not a bloodborne disease.

The nurse suspects that a coworker has a substance use disorder. Which finding should the nurse use to confirm this​ suspicion? (Select all that​ apply.) A) Wears long sleeves despite hot weather. B) Frequently asks peers for breath mints. C) Wears more makeup than other nurses. D) Breath smells like mouthwash. E) Face is frequently flushed when indoors.

A, B, D, E ​Rationale: Potential signs of an impaired nurse include facial​ flushing; frequent use of breath​ mints, mouthwash, and​ perfumes; and wearing long sleeves despite hot weather to cover needle tracks on arms. Wearing makeup is not a warning sign of an impaired nurse.

The parents of a child with cerebral palsy​ (CP) are concerned about possible future health problems. The nurse knows the client is at risk for which​ complication? (Select all that​ apply.) A) Decreased cognitive ability B) Premature aging C) Hypotension D) Depression E) Urinary incontinence

A, B, D, E ​Rationale: The client with CP is at risk for multiple comorbidities to include​ depression, decreased cognitive​ ability, urinary and bowel​ incontinence, and premature aging. The client with CP is at risk for developing​ hypertension, not hypotension.

The nurse is teaching a new mother about infant care. Which should the nurse include to prevent the development of failure to thrive​ (FTT)? (Select all that​ apply.) A) Importance of touch B) Establishment of trust C) Expected development changes D) Use of formula supplements E) Auditory stimulation

A, B, E

The nurse is caring for a client experiencing withdrawal from a central nervous system​ (CNS) depressant. Which collaborative treatment should the nurse expect to ​implement? (Select all that​ apply.) A) Inducing vomiting B) Using activated charcoal to absorb the drug C) Recommending group therapy D) Taking vital signs every hour E) Keeping the client awake

A, B, E Rationale: During withdrawal from CNS​ depressants, treatment includes keeping the client​ awake, inducing vomiting while employing aspiration​ precautions, and using activated charcoal to absorb the drug. Vital signs are taken more frequently than hourly and should be monitored every 15 minutes. Group therapy would be beneficial after the withdrawal of the substance

The nurse is teaching the parents of a client with growth and development alterations. Which independent intervention should the nurse provide to the client or​ family? (Select all that​ apply.) A) Ensure the client is properly fitted with orthotic​ devices, if prescribed B) Provide instruction on the creation of a safe home environment C) Prescribe medication for treatment D) Provide speech therapy E) Facilitate connections with support groups and financial aid services

A, B, E ​Rationale: The nurse should facilitate connections with support groups and financial aid​ services, provide instruction on the creation of a safe home​ environment, and ensure that the client is properly fitted with orthotic devices. The nurse cannot prescribe medication or provide speech therapy

The pediatric nurse would avoid using therapeutic play with a hospitalized 6-year-old at which times?Select all that apply.? A) During a bedside procedure B) During preoperative teaching C) At bedtime D) When the child is stressed E) Before a diagnostic test

A, C Explanation: Play is not recommended at bedtime to maintain a restful environment, or when the child needs to remain quiet, such as during a procedure. A quiet and calm environment will promote sleep. Play is a very effective teaching intervention. It is often used before surgery and diagnostic tests to aid understanding of these events. Play is not recommended at bedtime to maintain a restful environment, or when the child needs to remain quiet, such as during a procedure. Play is therapeutic to help the child express feelings during stressful times.

Which intervention should the nurse teach the parents of a​ school-age client with​ attention-deficit/hyperactivity disorder​ (ADHD)? (Select all that​ apply.) A) Praising all positive behaviors B) Giving​ time-outs only for the worst negative behaviors C) Turning off the television when the client is doing homework D) Maintaining a consistent bedtime routine and time E) Asking the healthcare provider to provide drug holidays every other week

A, C, D Rationale: Children with ADHD do best with structured and consistent​ routines, which include maintaining a consistent time and routine for bedtime and praising all positive behaviors. Reducing environmental stimuli by turning off the television will also help the child with ADHD. To reduce stimulant​ abuse, drug holidays during weekends and school​ breaks, when the child does not take​ medication, can be discussed with the healthcare provider. Like positive​ behaviors, all negative behaviors should have consistent​ consequences, not just the worst ones.

The mother of a​ 4-year-old child with cerebral palsy​ (CP) asks how this health problem occurred. Which prenatal insult should the nurse explain as a possible​ cause? (Select all that​ apply.) A) Prematurity B) Brain injury C) Fetal viral infection D) Genetic factors E) Hyperbilirubinemia

A, C, D Rationale: Prematurity is an etiology of CP that occurs before birth. Fetal viral infection is an etiology of CP that occurs before birth. Genetic factors are an etiology of CP that occurs before birth. Hyperbilirubinemia is an etiology of CP that occurs after birth. Brain injury is an etiology of CP that occurs after birth.

The nurse in the employee health clinic knows that nurses are at high risk of developing substance abuse problems. Which should the nurse identify as a reason for this​ risk? (Select all that​ apply.) A) Easy access to drugs B) Spending time with coworkers outside work C) Pressures in the workplace D) Frequent contact with drugs E) Working​ 12-hour shifts

A, C, D ​Rationale: Easy access to​ drugs, pressures in the​ workplace, and frequent contact with drugs are reasons why nurses are at high risk of developing substance abuse problems. There is no correlation between nurses being at high risk of substance abuse and working​ 12-hour shifts or spending time with coworkers outside the workplace environment.

The nurse is caring for a client who overdosed on LSD. Which intervention should the nurse​ provide? (Select all that​ apply.) A) Reduce environmental stimuli. B) Administer opioid antagonist as ordered. C) Speak slowly and clearly with the client. D) Have one person​ "talk down the​ client." E) Administer renal dialysis as prescribed.

A, C, D ​ Rationale: For LSD​ overdose, the nurse should reduce the environment stimuli and have one person​ "talk down the​ client." Speaking slowly and clearly with the client is also required. Renal dialysis is used for​ alcohol, barbiturate, or benzodiazepine​ overdose, and an opioid antagonist is used for​ heroin, meperidine,​ morphine, or methadone overdose. For LSD​ overdose, the nurse can expect a benzodiazepine or chloral hydrate to be used.

The nurse is assessing a​ 3-year-old child with autism spectrum disorder​ (ASD). In which area should the nurse expect to find​ impairments? (Select all that​ apply.) A) Social interactions B) Ability to engage in complex thought process C) Ability to organize responses to situations D) Social adaptability E) Communication

A, C, D, E ​Rationale: Impairments are noted in the social interactions and ability to adapt socially at the appropriate age level. The young child with ASD will have a decreased ability to communicate as well as an inability to organize situational responses.​ Developmentally, the​ 3-year-old is not old enough for complex thought

The nurse is teaching a class about stress reduction techniques in relation to substance abuse. Which should the nurse include in the​ lesson? (Select all that​ apply.) A) Effective coping skills B) Social drinking C) Abdominal breathing techniques D) Meditation E) Progressive muscle relaxation

A, C, D, E ​Rationale: Important teaching regarding substance abuse includes stress reduction. This may include a variety of techniques including​ imagery, meditation, muscle​ relaxation, breathing​ techniques, and effective coping skills. In substance​ abuse, alcohol should be avoided​ entirely, even in medications containing alcohol such as cough medicine.

The nurse is teaching high school students about substance abuse. Which should the nurse include about the risk factors for becoming addicted to a​ substance? (Select all that​ apply.) A) Family history of drug abuse B) Family involvement in​ child's life C) Poor social skill development in the child D) Peer pressure E) Depression

A, C, D, E ​Rationale: Poor social​ skills, peer​ pressure, family history of substance​ abuse, and depression are all risk factors for developing a substance abuse problem. Family involvement in a​ child's life is not a risk​ factor; however, lack of family involvement is.

Cystic​ fibrosis- (CF-) related digestive problems mean that many children with the disease have a hard time consuming adequate nutrients. Which condition should the nurse expect as a resultant​ effect? (Select all that​ apply.) A) Delayed growth and development B) Vomiting C) Poor weight gain D) Diarrhea E) Failure to thrive

A, C, E ​Rationale: Cystic​ fibrosis-related digestive problems mean that many children with the disease have a hard time consuming adequate nutrients. This may lead to poor weight​ gain, delayed growth and​ development, and possibly failure to thrive. To counter these problems parents may be asked to provide vitamin​ supplements, extra calories via nutritional​ supplements, and pancreatic enzyme supplementation. Diarrhea and vomiting are not hallmark symptoms of​ CF; constipation is more common.

The nurse is teaching a group of parents about​ attention-deficit/hyperactivity disorder​ (ADHD). Which psychosocial history consideration should the nurse include when addressing this​ group? (Select all that​ apply.) A) Excessive talking B) Viewed as overachiever C) Interrupts others D) High​ self-esteem E) Ostracized by peer group

A, C, E ​Rationale: Hyperactivity,​ impulsivity, and inattentiveness in the client with ADHD often manifest as excessive talking and interruption of others. Because of these disruptive​ behaviors, clients with ADHD are also often ostracized by their peer group and have low​ self-esteem. ADHD can cause difficulty at school and​ work, so clients are often viewed as​ underachievers, not overachievers.

The nurse is providing teaching to parents regarding developmental milestones that should be expected by the end of the eighth month of infancy. The nurse determines that the parents understand this teaching when they correctly identify which​ milestone? (Select all that​ apply.) A) Begins using the pincer grasp B) Stands without assistance C) Plays​ peek-a-boo D) Transfers objects from hand to hand E) Sits alone without assistance

A, D, E Rationale: By the end of the eighth​ month, the infant should be able​ to: transfer objects from hand to​ hand, sit alone without​ assistance, and begin using the pincer grasp. Standing without assistance and playing​ peek-a-boo is expected between 10 to 12 months.

Which medication should the nurse expect to find on the medication administration record​ (MAR) for a child with autism spectrum disorder​ (ASD)? (Select all that​ apply.) A) Selective serotonin reuptake inhibitor​ (SSRI) B) Beta blocker C) Angiotensin-converting enzyme​ (ACE) inhibitor D) Mood stabilizer E) Stimulant

A, D, E Rationale: While there is no medication to cure​ ASD, medications are prescribed to manage behaviors and symptoms. These medications include​ stimulants, SSRIs, and mood stabilizers. ACE inhibitors and beta blockers are used to treat hypertension.

The nurse is helping develop a safety plan with the parents of a​ nonverbal, school-aged child. Which information is most appropriate for the nurse to include in the​ plan? (Select all that​ apply.) A) Advise the family to notify the local emergency dispatch center that a client with special needs lives there. B) Have the parents demonstrate how to dial 911 in case of an emergency. C) Advise the family to notify the local hospital and clinic that a client with special needs lives there. D) Have the child demonstrate how to dial 911 in case of an emergency. E) Assist the family in finding adaptive equipment the child can use to participate in different activities.

A, D, E ​Rationale: It is important for the parents to notify the local emergency dispatch that a person with special needs lives at that number. In case of an​ emergency, the personnel who respond will be able to interact appropriately with the client. Adaptive equipment is important for a person with special needs to be able to participate in different activities safely. It is not necessary to contact the local hospital and clinic if the dispatch has already been notified. It is important that the nonverbal​ client, not the​ parents, can demonstrate dialing 911 or other emergency​ numbers, in case the client must do so in an emergency

The nurse educator is teaching a group of new nurses about pregnancy in cystic fibrosis​ (CF). Which statement should the nurse include in the​ teaching? (Select all that​ apply.) A) ​"The outcome of the pregnancy depends on the​ mother's health." B.) "CF mothers have a lower than average risk of gestational​ diabetes." C.) "A cesarean section is necessary for most​ cases." D) "Some CF medications may need to be discontinued until after​ pregnancy." E) "Nutritional supplementation is usually necessary for maternal and fetal​ well-being."

A, D, E ​Rationale: Many women with CF can​ conceive, but the outcome of the pregnancy depends on the​ mother's respiratory health. Many CF women deliver​ naturally, with up to​ one-third requiring a cesarean section. Although most CF medications are safe during​ pregnancy, others like antibiotics may need to be discontinued until after delivery. Women with CF tend to have lower than average weight gain during​ pregnancy; therefore, supplements may be necessary for maternal and fetal health.

The nurse is teaching a parent group about growth and development. Which factor should the nurse include in explaining how culture​ and/or ethnicity can influence growth and​ development? (Select all that​ apply.) A) Genetic variations B) Temperamental characteristics C) Identity establishment D) Nutritional practices E) Social interaction patterns

A, D, E ​Rationale: Social interaction​ patterns, genetic​ variations, and nutritional practices of various cultural or ethnic groups can influence growth and development. Identity establishment and temperamental characteristics are not cultural or ethnic influences on growth and development.

The nurse is talking to a group of new nurses about techniques to promote airway clearance in the client who has cystic fibrosis​ (CF). Which intervention should the nurse include in the​ discussion? (Select all that​ apply.) A) Administering mucolytics before chest physical therapy​ (CPT) B) Administering chest physical therapy​ (CPT) fewer times during an exacerbation C) Avoiding assisting​ caregivers, allowing them to learn by doing D) Teaching the client huffing and coughing E) Avoiding cough suppressants to avoid an airway obstruction

A, D, E ​Rationale: The nurse should teach the client techniques to clear the airway such as huffing and coughing. Administering mucolytics before CPT helps loosen secretions so they may be expelled. The nurse should assist the client and caregivers during therapy or teach them how to do the therapy themselves. During an​ exacerbation, clients may need CPT as often as four times a​ day, up to an hour each time. Cough suppressants should be​ avoided, or the client may be at risk for an obstructed airway. OK

The nurse is teaching a caregiver about treatment for failure to thrive​ (FTT). Which statement made by the caregiver should indicate the need for further​ teaching? (Select all that​ apply.) A) ​"I hope my baby will not need​ surgery; that idea scares​ me." B) ​"Nutritional supplements will help meet the caloric​ requirements." C) "I can monitor height and weight at home to see if any progress is being made between doctor​ visits." D) "Most babies do not sleep well​ anyway; my baby will sleep when she is​ tired." E) "Medications are given daily to treat this​ condition."

A, D, E ​Rationale: Treatment of FTT includes reestablishing eating and sleeping patterns for the client. Surgery is necessary only if an organic cause of FTT is identified. There are no medications used in the treatment of FTT. Monitoring height and weight to assess progress and providing nutritional supplements indicate appropriate understanding of treating FTT

An inexperienced mother is playing with her 8-month-old in the playroom. The nurse has taught the mother about toys that are developmentally appropriate for the child. The nurse will conclude that teaching has been successful when the mother selects which type of toy?Select all that apply.? A) A soft ball B) A puzzle with large pieces C) A wagon D) A rattle E) A set of blocks

A, E Explanation: Objects that can be grasped and banged together, such as blocks, develop manipulation skills and are most appropriate for an 8-month-old infant. Pleasure is experienced from the feel and sounds of these activities. A wagon may be used by preschoolers and toddlers. A large-piece puzzle may be used by preschoolers and toddlers. Rattles are recommended for infants ages 1 to 6 months.

The nurse is caring for a client with an addiction to cocaine. Which medication should the nurse expect to be​ prescribed? (Select all that​ apply.) A) Dopamine agonists B) Opioids C) Antipsychotics D) Opioid antagonists E) Antidepressants

A, E Rationale: Pharmacologic treatment for cocaine abuse includes antidepressants and dopamine agonists. Opioids and opioid antagonists are pharmacologic treatment measures for opiates.

A​ small-for-gestational age neonate is showing signs of poor development. Which factor should the nurse identify that increases this​ client's risk of cerebral palsy​ (CP) before or during​ birth? (Select all that​ apply.) A) Premature birth B) Injury to the cerebral cortex C) Hyperbilirubinemia D) Neonatal sepsis E) Fetal viral infection

A,B,E ​Rationale: Most cases of CP are caused before or during birth by a brain​ insult; this includes premature​ birth, fetal viral​ infection, and injury to the cerebral cortex. CP can also develop after birth to age 2​ years, when it can be caused by neonatal sepsis and hyperbilirubinemia

Which condition should the nurse expect to be included in the health history of a client with cystic​ fibrosis? (Select all that​ apply.) A) Using effort to breathe B) Feeling rested C) Performing effective use of huffing D) Noticing changes in sputum E) Experiencing periods of dyspnea

A,C,D,E ​Rationale: Health history for cystic fibrosis should include breathing specifics including​ dyspnea, huffing, and the effort required to breathe. Most clients will feel​ fatigued, not rested. Changes in sputum should also be reported along with changes in​ nutrition, supplement, and medication use.

A toddler is admitted for severe anemia, which is found to be dietary in nature. What recommendation would the nurse make to the parents to enhance dietary iron intake to promote healthy growth and development? A) Increase fat-soluble vitamins in the diet. B) Limit milk to no more than 32 oz/day. C) Limit foods that are high in protein in the daily caloric requirement. D) Include grains and legumes in the daily intake

B Excessive milk consumption should be discouraged, especially more than 1 liter/day (32 oz), since it is a poor source of iron. Fat-soluble vitamins will not increase absorption or utilization of iron. Although grains and legumes are good sources of nutrients, they are not especially high in iron. Foods high in protein should be encouraged, and especially food proteins of animal origin and organ meats, such as liver.

When discussing health promotion with young working adults, the nurse should focus prevention measures on which disorder? A) Heart disease B) Obesity C) Hypoglycemia D) Cancer

B Explanation: Heart disease occurs with greater frequency with increasing age; this is not the most appropriate prevention measure on which the nurse should focus with young adults. Hypoglycemia is not a common disorder among young adults. Young adults as a group are at risk for improper eating habits and, if exercise is inadequate, this could lead to obesity. Obesity increases the risk of diseases such as atherosclerosis, hypertension, and heart disease. Cancer occurs with greater frequency with increasing age; this is not the most appropriate prevention measure on which the nurse should focus with this age group.

The parents of a​ school-age child newly diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD) ask why the child needs a physical in addition to examinations made at home and at school. Which response should the nurse​ make? A) "The physical exam will allow the healthcare provider to explore the possibility of other mental health​ issues, such as​ depression, anxiety, learning​ disorder, or conduct disorder your child may​ have." B) "We need to rule out neurologic diseases and other health problems in your child that may affect treatment of​ ADHD." C) "We need to see whether your child has the physical characteristics that go along with the behaviors of ADHD to correctly diagnose​ ADHD." D) "The healthcare provider will be able to give you better strategies for helping your child focus at home and at​ school."

B Rationale: A physical examination will rule out neurologic diseases and other health problems that may mimic ADHD or affect its treatment. There are no physical characteristics of ADHD that can be found with a physical exam. ADHD is diagnosed from a careful psychosocial history and questionnaires. The nurse is equally as qualified as the healthcare provider to provide strategies to help the client focus. A mental health specialist diagnoses other mental health issues using interviews and​ questionnaires, not a physical exa

The nurse visits the home of a toddler with failure to thrive​ (FTT). Which outcome should indicate to the nurse that care has been​ effective? A) Having a temper tantrum B) Good eye contact C) Refusing to eat finger foods D) Sleeping on the sofa

B Rationale: The toddler maintaining good eye contact is an indication that care has been effective. Sleeping on the sofa and having a temper tantrum would not help determine the outcome of care. Refusing food indicates that care has not been successful.

The school nurse is talking to the mother of a​ school-aged child recently diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD). While referring to a possible plan of​ care, which is most appropriate for the nurse to discuss with the​ mother? A) Early intervention plan B) 504 plan C) Individualized family service plan​ (IFSP) D) Individualized education plan​ (IEP) E) ADHD does not require a special plan of care

B ​Rationale: A child with special health needs may benefit from a 504 plan that the interprofessional team and parents develop. These plans may include accommodations​ (such as sitting at the front of the​ class) or ensure the provision of​ health-related interventions. An individualized family service plan​ (IFSP) identifies the​ child's and​ family's strengths and weaknesses and designs activities and goals to help the child meet developmental milestones. An individualized education plan​ (IEP) is an educational support tool for addressing developmental needs. An early intervention plan is considered from birth to 3 years of age. ADHD will likely require a plan of care to help the child succeed in school.

The nurse is planning care for a client who is diagnosed with autism spectrum disorder​ (ASD). Which goal is appropriate for the nurse to​ include? A) The client will remain free from infection. B) The client will display developmental progress. C) The client will demonstrate negative communication skills. D) The client will engage in private activities to stimulate learning.

B ​Rationale: An appropriate goal when providing care to a client diagnosed with ASD is for the client to display developmental progress. Other appropriate goals include the client remaining free of​ injury, the client demonstrating positive communication​ skills, and the client participating in activities with family members or small groups of peers.

The nurse is teaching the parents of a client with​ attention-deficit/hyperactivity disorder​ (ADHD) about the prescribed medication methylphenidate​ (Ritalin). Which statement from the parents reflects an understanding of the medication​ regimen? A) "We should restrict calories due to possible weight​ gain." B) "We can stop giving the medication during the​ summer." C) "The medication can be given any time of the​ day." D) "We should observe for excessive sleepiness during the​ day."

B ​Rationale: Clients on stimulant medications go on a drug holiday during the summer breaks. Clients who are on stimulant medications can experience insomnia and​ anorexia; thus, calories would not be restricted. Excessive sleepiness is generally not observed.

Which teaching point is important for the nurse to include in the plan of care for a client who is diagnosed with autism spectrum disorder​ (ASD)? A) Keeping the same pediatric healthcare provider for all children in the family B) Establishing a routine C) Focusing on limitations in order to see progress in care D) Maintaining the home as a​ treatment-free zone

B ​Rationale: Clients who are diagnosed with ASD thrive when routines are established and followed. The family should consider seeking a healthcare provider who has experience in treating a child with ASD. Therapies must be practiced and implemented in the home environment in order to be effective. The family would focus on the​ child's strengths, not the​ child's limitations.

Which resource should the nurse expect the healthcare provider to use to confirm the diagnosis of autism spectrum disorder​ (ASD)? A) Teaching Social Communication to Families with Autism B) Diagnostic and Statistical Manual of Mental Disorders C) The Autism Handbook D) The Mental Health Rights Manual

B ​Rationale: Criteria for diagnosis can be found in the American Psychiatric​ Association's Diagnostic and Statistical Manual of Mental Disorders​, 5th edition​ (DSM-5), which includes screening tests to identify tendencies consistent with ASD. Although the other resources may be helpful in teaching the client and the family about​ ASD, they are not used as a diagnostic tool

The nurse assesses that a client has reached physical growth milestones but has not achieved cognitive developmental milestones. Which factor should the nurse consider other than developmental​ disorders? A) Cerebral palsy B) Parental interaction C) Genetic abnormalities D) Child temperament

B ​Rationale: Family is an important environmental factor that plays an essential role in child development. Parenting influences risk and protective​ factors, personality​ characteristics, and developmental outcomes. Cerebral palsy is a physical disability. Genetic abnormalities would typically impact both growth and development. Child temperament is not a known factor that would impact the ability to achieve cognitive developmental milestones

Which characteristic is typically seen less in​ girls, when compared with​ boys, having​ attention-deficit/hyperactivity disorder​ (ADHD)? A) Anxiety B) Impulsiveness C) Mood swings D) Cognitive problems

B ​Rationale: Girls with ADHD typically show less aggression and impulsiveness than boys. Girls tend to show more​ anxiety, mood​ swings, social​ withdrawal, rejection, and cognitive and language problems

The nurse is tasked with teaching a client with cystic fibrosis and her mother about chest physical therapy​ (CPT). Which warning is most important for the nurse to​ include? A) Hold each position for at least 10 minutes. B) Percuss or vibrate only over the upper ribs and never over the​ sternum, breastbone,​ stomach, or lower ribs and back. C) Percuss or vibrate only over the​ sternum, breastbone,​ stomach, or lower ribs and back and never the upper ribs. D) Perform percussion only when the stomach is full.

B ​Rationale: Percuss or vibrate only over the upper ribs and never over the​ sternum, breastbone,​ stomach, or lower ribs and back. Perform percussion or postural drainage only when the stomach is empty. The ideal time is before a meal. Hold the chosen postural position for at least 5 minutes while percussing the chest in the prescribed manner.

The nurse is observing a teen client with​ attention-deficit/hyperactivity disorder​ (ADHD) at home. Which observation should indicate to the nurse that client outcomes have been​ met? A) The client receives poor grades on homework for not completing assignments as requested. B) The client receives several text messages from friends and does not respond until after asking permission to do so. C) The client talks​ incessantly, jumping from one topic to another. D) The client folds half a basket of laundry and leaves the rest to read a magazine.

B ​Rationale: Text messaging is an​ age-appropriate social interaction for the client. While they can be distracting and can cause the client to lose​ focus, the client did ask permission before​ responding, which indicates that the client is controlling impulsivity and inattentiveness. An inability to complete tasks and follow directions indicates that client goals have not been met. Excessive talking is another sign that client goals have not been met.

The nurse observes a new staff member completing a physical assessment of a client with failure to thrive​ (FTT). For which information should the nurse​ intervene? A) Eye contact B) History of the pregnancy and birth C) Touching D) Cuddling

B ​Rationale: The nurse should observe for eye​ contact, touching, and cuddling while conducting the physical assessment of the client. The history of the pregnancy and birth is assessed during the health history portion of the nursing assessment.

Which activity should be appropriate for the nurse to suggest to parents to aid in the development of their​ toddler's gross motor​ skills? A) Coloring with large crayons B) Playing with a soft ball and bat C) Using a toy telephone D) Doing wooden puzzles

B ​Rationale: The toddler from age 1-3 years old can develop gross motor skills by such activities as playing with a soft ball and​ bat, riding a big wheel​ tricycle, molding water and​ sand, and tossing a ball or beanbag. Fine motor skills would be refined with the other choices.

The nurse is teaching the parents of a child with cystic fibrosis​ (CF) about physical activity. Which statement by the parents indicates the teaching has been​ effective? (Select all that​ apply.) A) "Our child should not participate in physical activity because of​ CF." B) "Our child should eat during​ exercise, even if he is not​ hungry." C) "Our child should keep fluids high in salt handy during​ activity." D) ​"Our child should eat salty snacks during​ exercise." E) ​"Our child should limit physical activity because of his weak​ lungs."

B, C, D Rationale: An individual with CF should keep salty snacks and drinks handy during exercise and should consume them even if he is not hungry or thirsty. Physical activity is not limited in those with​ CF; it is encouraged because it helps them to maintain​ weight, increases gastric​ motility, and helps strengthen respiratory muscles.

The nurse is caring for a client with a history of substance abuse. Which statement should indicate to the nurse that the client is progressing through an effective course of​ recovery? (Select all that​ apply.) A) "I don't think I really was​ addicted; I just went through a bad​ patch." B) "I haven't used drugs in over 2​ years." C) "I've been back in school for the last two​ semesters." D) "I know I will always need to use the tools from the addiction​ program." E) "I still like hanging with my old​ friends."

B, C, D Rationale: Statements that indicate​ abstinence, an awareness of addiction​ issues, and a return to normal functioning are indicative of recovery. Statements that use such ego defenses as denial and minimization are not signs of effective recovery

he nurse is teaching parents about the temperament theory. Which characteristic of this theory should the nurse​ include? (Select all that​ apply.) A) The​ "mean" child B) The​ "easy" child C) The​ "slow-to-warm-up" child D) The​ "difficult" child E) The​ "hyperactive" child

B, C, D Rationale: The​ "easy" child,​ "difficult" child, and​ "slow-to-warm-up" child are all characteristics of the temperament theory. The​ "mean" child and​ "hyperactive" child are not terms that are associated with the temperament theory.

The nurse is preparing discharge instructions for the parents of a child with cerebral palsy​ (CP). Which instruction should the nurse include to promote safety for this​ child? (Select all that​ apply.) A) Splints and braces B) Seat belts in strollers and wheelchairs C) Helmet to protect against head injuries D) Adaptive seating for automobile transportation E) Range-of-motion exercises

B, C, D ​Rationale: A client who has frequent falls​ and/or seizures may require a helmet to protect against head injury. Adaptive seating in an automobile may be required to ensure​ proper, safe restraint. Use of seat belts in wheelchairs or strollers will prevent spastic movements from resulting in falls. Use of splints and braces and​ range-of-motion exercises will promote mobility and muscle​ strength; they are not used to promote safet

The nurse is assessing a​ 4-month-old infant. Which developmental milestone should the nurse expect the infant to have mastered by this​ time? (Select all that​ apply.) A) Sits without assistance B) Turns head toward voices and sounds C) Forms hand into a fist D) Looks at and plays with own fingers E) Holds a bottle

B, C, D ​Rationale: An infant that is 4 months old should have met the following​ milestones: forming hands into a​ fist, looking at and playing with own​ fingers, and turning head toward voices and sounds. Sitting without assistance happens around 8 months. Holding a bottle occurs between 4 and 6 months.

Which instruction should the nurse include when teaching parents strategies to enhance communication with a child diagnosed with autism spectrum disorder​ (ASD)? (Select all that​ apply.) A) Using complex words to stimulate the​ child's vocabulary B) Using​ pictures, computers, or other visual aids C) Using​ short, direct sentences D) Considering using sign language E) Speaking loudly

B, C, D ​Rationale: Clients with ASD have impaired communication skills. Strategies to improve communication include using​ short, direct sentences that are easy to​ understand, supplementing verbal communication with the use of​ pictures, computers, or other visual​ aids, and using sign language. Deafness is not a clinical manifestation of​ ASD, so speaking loudly will not improve communication and will distress the client.​ Simple, not​ complex, words and sentences are best for communication with the client with ASD.

The nurse is providing discharge teaching to a client with cystic fibrosis​ (CF). Which intervention should the nurse include that will promote effective​ breathing? (Select all that​ apply.) A) Ensure the floating marker is as high as possible during incentive spirometry. B) Administer bronchodilators before any airway clearance techniques. C) Contact the healthcare provider if a decrease in appetite or weight occurs. D) Use incentive spirometry to practice taking​ slow, deep breaths. E) Administer cough suppressants if client is unable to sleep due to coughing.

B, C, D ​Rationale: The client with CF should be taught to administer bronchodilators before airway clearance techniques or inhaled mucolytics. This helps open the airways and lets more medication penetrate the small airway. When using incentive​ spirometry, the client should take​ slow, deep breaths and aim for the floating marker to stay within a certain​ range, not as high as possible. If the client experiences an increase in fatigue or a decrease in appetite or​ weight, the healthcare provider should be notified.

The nurse is caring for a pregnant client with a substance use disorder. Which substance type should the nurse expect to be treated with medication​ therapy? (Select all that​ apply.) A) Cocaine B) Nicotine C) Opioid D) Alcohol E) Narcotic

B, C, D, E ​Rationale: Alcohol,​ nicotine, and​ narcotics, including​ opioids, are substances that medication therapy is used to treat abuse. Medication therapy is not beneficial and would not be appropriate for an addiction to cocaine

The nurse is providing care to a pregnant client. Which teaching should the nurse provide to the client to reduce the potential risk of developmental alterations in the​ baby? (Select all that​ apply.) A) Adequate proximodistal growth B) Nutrition C) Avoidance of harmful substances D) Psychosocial developmental milestones E) Prescription and nonprescription medication use

B, C, E ​Rationale: Some developmental delays can be avoided through prenatal client teaching on​ nutrition, avoiding harmful​ substances, and the proper use of prescription and nonprescription medications. Information on psychosocial developmental milestones and proximodistal growth are not appropriate at this time.

The parents of a young client newly diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD) are concerned about the school environment and the​ child's grades. Which suggestion should the nurse encourage the parents to discuss with the​ child's teacher?​ (Select all that​ apply.) A) Don't allow the child to do special tasks or run errands without supervision. B) Place the child in the front of the classroom close to the teacher. C) Remind the child to pay attention in front of the class. D) Provide a quiet area for examinations and extra time if necessary. E) Place the child in the back of the classroom.

B, D Rationale: The child should be placed in the front of the​ classroom, not in the back of the classroom. A quiet area to take examinations and additional time if necessary would be encouraged. The child should not be called out in front of the class. The child should be allowed to do special tasks or run​ errands, within​ reason, to provide additional opportunities for movement.

The nurse is collaborating with the registered dietitian to prepare client teaching about dietary recommendations for clients with cystic fibrosis​ (CF). Which statement should the nurse​ include? (Select all that​ apply.) A) ​"Fluid restriction is important in clients with​ CF." B)"Clients with CF should eat whenever they are​ hungry." C) ​"Oral pancreatic enzymes need to be taken after every​ meal." D) ​"Increase salt intake during hot weather or when​ exercising." E) "A high-calorie,​ high-fat diet is recommended in​ CF."

B, D, E Rationale: A​ high-calorie, high-fat diet is typically not associated with​ health; however, a client with CF requires​ this, if it is supplemented with​ fruits, vegetables, and grains. Clients with CF should eat whenever they are hungry and may snack as often as every hour. Eating should be​ regular, even if they are not hungry. Pancreatic enzymes are taken before each​ meal, not​ after, to help with digestion. When CF clients are losing salt in sweat during summer months or during​ exercise, they should increase their salt intake. Fluid restriction is not necessary in CF as fluids help to decrease the viscous secretion

During a routine​ examination, the mother mentions that her​ 13-year-old son is constantly eating and is rapidly growing out of most of his clothes. Which statement should the nurse include in the response to the​ mother? (Select all that​ apply.) A) "Most growth at this age takes place in long bones of the arms and​ legs." B) "You can expect height and weight increases to last over the next few​ years." C) "Growth in all children occurs in a cephalocaudal​ direction." D) "Boys often experience a prepubescent growth spurt at this​ age." E) "Nutritional needs increase with growth​ spurts."

B, D, E Rationale: The prepubescent period is marked by a growth spurt at about age 10 for girls and 13 for boys. Nutritional needs increase with growth​ spurts, and there is dramatic height and weight increase​ (usually over a period of 2-3 ​years). Growth in infants occurs in a cephalocaudal​ direction, but not in this stage. Although bone growth is​ continuing, the majority of long bone growth does not occur in this stage

The parents state that the behavior of a child with​ attention-deficit/hyperactivity disorder​ (ADHD) is creating stress for the environment in their home. Which suggestion should the nurse encourage the parents to consider to minimize this​ stress? (Select all that​ apply.) A) Allow the child as many choices as possible to decrease conflict in the home. B) Provide appropriate rewards when the child meets expected behavior. C) Allow the child to listen to music during study time. D) Set boundaries and consequences. E) Make a schedule for​ bedtime, meals, and recreational activities.

B, D, E ​Rationale: Boundaries and consequences should be set for the child. When the child meets expected​ behaviors, appropriate rewards such as playing outside or riding a bike for 30 minutes should be allowed to continue to reinforce positive behaviors.​ Additionally, providing a schedule of​ activities, meals, and bedtime will provide structure within the home. The child should not listen to music during study time. And the child should not be allowed as many choices as possible because the child needs specific boundaries and expectations.

The nurse conducts an initial interview with a 10-year-old boy brought to the clinic by the parents. Which question should the nurse ask to establish rapport and credibility with the client? A) "Do you remember any medical problems or illnesses you had in the past?" B) "Do you have an idea of what you said or did that led your parents to bring you here today?" C) "Can you tell me a little bit about some of your hobbies or other things that you like to do?" D) "How do you think you get along with members of your family and friends?"

C Explanation: Children at 10 years of age are developmentally egocentric. Asking about interests and hobbies is nonthreatening and likely to foster establishment of rapport. Focusing on behavioral symptoms, such as what brought the client to the clinic, would be more appropriate once rapport has been established. Children often are uncomfortable talking about relationships with friends and family until they get to know a person better. Ten-year-old clients may be unconcerned about past medical problems or may not recall them; such questions do not promote initial rapport between nurse and client

The nurse discusses the risk of aspiration with the parents of an 18-month-old. To minimize this risk, the nurse recommends the parents avoid giving their child which food items? A) Apples, fruit juice, and raisins B) Oranges, crackers, and applesauce C) Cherries, peanuts, and hard candy D) Cheerios, toast, and bananas

C Explanation: Toddlers chew well but may have difficulty swallowing large pieces of food. Young children cannot discard pits (such as from cherries). Firm foods such as peanuts and hard candies are easily aspirated, while softer ones, such as cereal or raisins, are better tolerated.

The nurse is planning care for a newborn with a cleft palate. For which health problem should the nurse plan interventions for this​ client? A) Nonorganic failure to thrive​ (NFTT) B) Sleep deprivation C) Organic failure to thrive​ (OFTT) D) Colic

C Rationale: Cleft palate can cause OFTT. Causes of NFTT include lack of​ mothering, insufficient​ stimulation, and inadequate nutritional intake. Colic and sleep deprivation are not directly associated with a cleft palate.

Which medication should the nurse expect to be ordered to decrease inflammation for a client with cystic​ fibrosis? A) Bronchodilator B) Pancreatic enzymes C) Nonsteroidal​ anti-inflammatory agents D) Mucolytic

C ​Rationale: Airway inflammation is a hallmark of cystic fibrosis​ (CF). The most commonly prescribed nonsterioidal​ anti-inflammatory in CF is ibuprofen. A​ bronchodilator, albuterol, is used in the treatment of CF. A​ mucolytic, dornase, is helpful in decreasing thick mucus. Pancreatic enzymes may be prescribed to aid in digestion and absorption of nutrients.

The nurse is writing a plan of care for a client with failure to thrive​ (FTT). Which goal should the nurse make a priority for this​ client? A) The child will sleep through the night. B) The parent-child relationship will improve. C) The child will attain adequate growth and normal development. D) Complications from poor nutrition will be prevented

C ​Rationale: All the listed goals are​ important, but FTT is a feeding disorder and represents malnutrition. It is a priority for the client to have improved nutrition to assist with growth and development.

The nurse is assessing a client with suspected cystic fibrosis​ (CF). Which clinical manifestation should the nurse recognize as a hallmark sign of the disease that would support this​ suspicion? A) An increased amount of chloride in the nasal secretions B) A decreased amount of chloride in the sweat C) An increased amount of chloride in the sweat D) A decreased amount of chloride in the nasal secretions

C ​Rationale: An increased amount of chloride in the sweat is a hallmark manifestation and is one basis for diagnosis of cystic fibrosis. This results in mucus viscosity and respiratory problems such as a chronic cough and increased susceptibility to infections.

The nurse is preparing a teaching tool for the staff at an assisted living facility. Which statement should the nurse use to describe geriatric failure to thrive​ (GFTT)? A) Older adults are less active and require less caloric intake. B) It is part of the normal aging process. C) It is a disorder of undernutrition in an older adult. D) There is no disorder called geriatric failure to thrive.

C ​Rationale: Failure to thrive can affect any age group. Geriatric failure to thrive is a true undernutrition disorder. This health problem is not a normal part of the aging process. It is not caused by inactivity and the need for less caloric intake.

The mother of a teenage female client recently diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD) tells the​ nurse, "Our daughter has a male cousin who has​ ADHD, but he​ doesn't act anything like​ her." Which response should the nurse make to explain the​ difference? A) ​"Girls with ADHD tend to be diagnosed earlier than​ boys." B) ​"Girls with ADHD tend to show fewer language problems than boys with​ ADHD." C) "Girls with ADHD tend to show less impulsiveness than boys with​ ADHD." D) ​"Girls with ADHD tend to show more aggression than boys with​ ADHD."

C ​Rationale: Girls with ADHD tend to show less aggression and impulsiveness than boys with ADHD.​ However, girls show more​ anxiety, mood​ swings, social​ withdrawal, rejection, and cognitive and language problems. Girls are usually​ older, not​ younger, than boys at the time of diagnosis.

The caregiver of a​ 30-year-old client with cerebral palsy​ (CP) asks if there are any changes in health that might develop. Which response should the nurse​ make? A) "People with CP​ don't often live past​ 30." B) "It is impossible to predict which health changes he will​ experience." C) "He will likely develop signs of premature aging as a result of constant stress on the​ body." D) "He will gradually become more and more independent as the spasticity in the muscles​ diminishes."

C ​Rationale: In clients with​ CP, constant stress on the body can cause premature aging. Conditions such as​ hypertension, osteoarthritis, and atherosclerosis often develop before age 40. Numerous clients with CP do live past age​ 30, and this is increasing as symptom management becomes more effective. Independence usually does not increase as a result of​ aging, but the manifestations may become more severe or result in further complications.

The nurse is teaching a group about the cognitive theory of development. The nurse determines that teaching has been effective when the group identifies which components of the cognitive theory of​ development? A) Assimilation, resilience, and temperament B) Assimilation, adaptation, and​ self-efficacy C) Assimilation, accommodation, and adaptation D) ​Self-efficacy, temperament, and adaptation

C ​Rationale: The cognitive theory of development includes​ assimilation, accommodation, and adaptation.​ Self-efficacy is a component of social learning theory. Temperament is a component of the temperament theory of development. Resilience is a component of the resilience theory.

The nurse is discussing developmental theories with a parent group. Which theory should the nurse identify as involving the development of right and​ wrong? A) Resilience theory B) Ecologic theory C) Moral theory D) Spiritual theory

C ​Rationale: The moral theory of development is a complex theory that involves the development of values necessary to live with others in society. Ecologic theory involves the development of hereditary capability versus environmental effects. Resilience theory refers to the ability to function with healthy responses in situations of high stress and adversity. Spiritual theory deals with the development of an understanding of how an individual finds meaning in relation to her world.

A client with​ attention-deficit/hyperactivity disorder​ (ADHD) taking atomoxetine​ (Strattera) asks about eliminating sugar from the diet and taking ginkgo biloba to control symptoms. Which response should the nurse make about complementary and alternative therapies for​ ADHD? A) ​"Taking medication​ isn't really that​ bad, especially since it is the only effective way to control your symptoms and let you live a normal​ life." B) "You can replace your medication with these alternative treatments if you​ like, but be sure to tell your healthcare provider about​ them." C) "These are popular alternative​ treatments, but scientific evidence does not consistently support their​ effectiveness." D) "Why don't we ask your healthcare provider to prescribe a different medication instead of the one​ you're taking, if​ you're worried about​ it?"

C ​Rationale: To​ date, there is no consistent evidence that elimination​ diets, dietary​ supplements, or herbs are effective in treating ADHD. Telling this to the client in a​ factual, nonjudgmental manner is the best response. The nurse does not have the authority to change the​ client's treatment regimen without approval from the healthcare​ provider, even if the nurse tells the client to tell the provider about the change. Neither suggesting a new medication nor minimizing the​ client's concerns addresses the​ client's interest in alternative​ therapies, and they do not acknowledge the​ client's concerns

The nurse is preparing a presentation on cystic fibrosis​ (CF). Which statement should the nurse include to describe the cause of the genetic mutation of​ CF? A) Absence or dysfunction of protein consumed by the mother B) Absence or dysfunction of a protein C) Absence or dysfunction of the cystic fibrosis transmembrane conductance regulator​ (CFTR) protein D) Absence or dysfunction of the tumor necrois factor​ (TNF) protein

C ​Rationale: The genetic mutation of cystic fibrosis is caused by the absence or dysfunction of the cystic fibrosis transmembrane conductance regulator​ (CFTR) protein, which is responsible for the regulation of chloride across cellular membranes. Chloride is essential to cellular​ function, including regulating water balance in the tissues. The water balance is needed to assure the production of mucus. Because of this imbalance​ thick, sticky mucus is created.

The nurse is caring for a client withdrawing from the hallucinogen LSD. Which nonpharmacologic treatment should the nurse anticipate being​ used? (Select all that​ apply.) A) Conducting group therapy B) Recommending individual therapy C) Ensuring low stimuli with minimal​ light, sound, and activity D) Having one person reassure and​ "talk the client​ down" E) Speaking slowly and clearly to the client

C, D, E ​Rationale: During withdrawal from​ LSD, nonpharmacologic treatment includes speaking slowly and clearly to the​ client; ensuring low stimuli with minimal​ light, sound, and​ activity; and having one person reassure and​ "talk the client​ down." Individual and group therapy would be beneficial after the withdrawal of the substance.

The charge nurse is developing plans to reduce the stress of a hospitalized, chronically ill 8-year-old child. Which approach by the nurse is most likely to improve the child's coping ability?Select all that apply. A) Have tutoring postponed until discharge. B) Allow 24-hour open visitation with peers. C) Provide care specifically designed for a school-age child. D) Caution against making any decisions while hospitalized. E) Offer the child some choices for activities such as bathing or ambulating.

C, E Explanation: Although visitation of peers is important, open visitation is usually recommended only for family members. Although visitation of peers is important, open visitation is usually recommended only for family members. Age-specific care is care that better meets the developmental needs of the hospitalized child. Depending on the status of the child's illness and resources available, tutoring may be recommended. Mutual decision making is beneficial for the child and family. Providing opportunity for choices is beneficial for the child to achieve some sense of control while being hospitalized.

Which screening assessment should the nurse use for a child demonstrating developmental delays associated with cerebral palsy​ (CP)? (Select all that​ apply.) A) Heel-shin test B) Phalen test C) Head turn D) Babinski reflex E) Diaper pull

C, E ​Rationale: All infants who show symptoms of developmental delay should be evaluated by using two simple screening assessments. The first is a diaper​ pull, which is conducted by placing a clean diaper on the​ child's face; the infant with CP will use one hand or will not remove the cloth at all. The other test is the head​ turn, which is conducted by turning the​ infant's head to one​ side; if the child has a persistent asymmetric tonic neck reflex beyond 6 months of​ age, this indicates a pathologic condition. The Babinski reflex does not indicate the presence or absence of CP. The Phalen test is used to assess for carpal tunnel syndrome. The heel-shin test is used with adults to determine nervous system integrity of the lower extremities.

The nurse considers that which physical change commonly associated with aging is most likely to require a reduction in medication dosage for an older adult client?Select all that apply.? A) Decreased efficiency in drug distribution B) Significant weight gain C) Increased rate of drug retention D) Decreased total body fluid proportionate to body mass E) Decreased rate of drug metabolism by the liver

C,D,E Explanation: Since elderly clients experience a decreased rate of drug excretion (and thus increased retention of drug), reduction of dosage would be appropriate. The decreased total body fluid proportion that accompanies physical aging increases the concentration of water-soluble drugs and requires lower dosing in older adults. Decreased efficiency in drug distribution would not correlate with a need to lower the dosage. Older adult clients experience a decreased rate of drug metabolism and thus a reduced dosage may be needed. Most older adults tend to lose weight as they age.

Which common neurological change that occurs in the healthy older adult would the nurse expect to note when performing a client assessment? A) Dysuria and incontinence B) Loss of touch sensation C) Peripheral neuropathy D) Presbyopia and presbycusis

D Explanation:Vision and hearing commonly deteriorate as part of the normal aging process. Nerve damage that can lead to loss of touch sensation can occur with diabetes or decreased blood flow from atherosclerosis. Dysuria and incontinence are related to relaxed muscle tone or sphincter damage. Peripheral neuropathy is a disease process that changes the sensations and motor function, such as diabetes mellitus. Prev Next Reset Notes Answer Review Save Exam Grade Exam

A​ 3-year-old child with failure to thrive​ (FTT) is having a​ 1-month follow-up assessment. Which should the nurse anticipate evaluating in this​ client? A) Improvement in socialization B) Achievement of food security C) Appropriate use of support systems D) Measurement of growth and development

D Rationale: A​ follow-up assessment should focus on measuring this​ client's growth and development. Support​ systems, food​ security, and socialization will not provide information about the success of care for FTT.

An​ 8-month-old baby with failure to thrive​ (FTT) is being discharged. Which goal should the nurse identify for this​ client? A) Increase activity. B) Adhere to a feeding schedule. C) Increase interaction with others. D) Improve nutritional intake.

D Rationale: Nursing care of the child with FTT is directed toward improving the​ child's nutritional intake with the goal of increasing the growth and health of the child. This may be accomplished through parent​ teaching; observation of​ child-parent interactions, especially during feeding​ times; and careful recording of height and weight on growth charts. Increased activity would burn more calories. A schedule in and of itself would not address the improved intake. Increased interaction would only be a benefit if it improved nutrition.

A​ 21-year-old client with cystic fibrosis​ (CF) is visiting the clinic because his condition is less controlled than usual. Which question by the nurse would help the client maintain his therapeutic​ regimen? A) ​"Do you need someone to help​ you?" B) ​"Are you not following your treatment​ plan?" C) ​"Are you having more trouble​ breathing?" D) "What is different in your regimen today from when your CF was more​ controlled?"

D ​Rationale: Asking​ open-ended questions allows the conversation to open up and the client to provide more information. Asking any other​ closed-ended question will not allow the nurse to easily obtain the information needed to better understand the​ client's symptoms.

The nurse is admitting a client with cystic fibrosis​ (CF) who is experiencing a pulmonary exacerbation. Which should the nurse include in the physical examination portion of the​ assessment? A) Level of fatigue B) Client positioning C) Overall appearance D) Nasal flaring

D ​Rationale: Client​ positioning, overall​ appearance, and level of fatigue are included in the observation and client interview portion of the assessment. Physical assessment includes vital​ signs, gastrointestinal, and respiratory assessment.

Which cause should the nurse recognize related to delayed puberty in an adolescent with cystic fibrosis​ (CF)? A) Medications prescribed B.) Thick, sticky secretions C.) High-calorie diet D) Delayed growth and development

D ​Rationale: Due to delayed growth and​ development, many adolescents with CF begin puberty 18-24 months later than their peers without CF. Some​ girls, however, do not experience menstruation due to​ disease-related nutritional deficiencies.

The nurse is caring for a family with a toddler experiencing gross motor delays. From which member of the interprofessional team should the nurse request an order for a consult for an​ evaluation? A) Occupational therapist B) Child psychologist C) Speech therapist D) Physical therapist

D ​Rationale: Gross motor delays need to be evaluated by a physical therapist. Language delays would be evaluated by a speech therapist. An occupational therapist can help with fine motor delays. A child psychologist would be consulted for overall cognitive delays.

A​ 1-year-old child is being evaluated for cerebral palsy​ (CP). Which finding should the nurse least expect to assess in this​ client? A) Arching of the back B) Developmental delay C) Strabismus D) Normal muscle tone in all extremities

D ​Rationale: Infants and children with CP do not exhibit normal muscle tone. Infants with cerebral palsy often exhibit arching of the back. Children with CP often experience delay in reaching developmental milestones. Strabismus is seen in children with CP.

Which recommendation should the nurse provide to help improve the health and endurance of a client with cystic​ fibrosis? A) Eat a​ low-calorie diet. B) Restrict fluids. C) Have a massage. D) Improve physical fitness.

D ​Rationale: Participating in regular exercise and fitness training activities can improve lung function and​ mood, and also maintain bone strength. A​ high-calorie and​ high-fat diet, along with increased fluid​ intake, is indicated with cystic​ fibrosis; not restrictions.​ Massage, used as a complementary and alternative medicine​ (CAM), may benefit the​ client's mood, but it is not a key in building strength and endurance.

A​ 7-year-old client with cerebral palsy​ (CP) is learning to​ self-feed. Which action should the nurse encourage to promote independence and success with​ self-feeding? A) Restricting attempts at​ self-feeding to 5 minutes B) Reassuring the child that having to be fed is nothing to be ashamed of C) Assisting the parents with total feeding D) Providing​ large, padded eating utensils

D ​Rationale: Providing​ large, padded utensils makes​ self-feeding easier and facilitates success with this endeavor. Children with CP should be encouraged to do as much as they can for themselves. Insisting on total feeding or not allowing prolonged periods of time to practice​ self-feeding does not help encourage independence.

The nurse is caring for an adolescent client newly diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD). Which nursing diagnosis should the nurse prioritize for this​ client? A) Pain, Chronic B) Development: Delayed, Risk for C) ​Mobility: Physical, Impaired D) Injury, Risk for

D ​Rationale: The client with ADHD is at increased risk for injury because the impulsivity and inattentiveness seen with this disorder are risk factors for antisocial​ behavior, substance​ abuse, and serious accidents. ​Mobility: Physical,​ Impaired; ​Pain, Chronic; and ​Development: Delayed, Risk for are not appropriate nursing diagnoses for clients with ADHD.​ (NANDA-I ©2014)

The nurse is reviewing the medical record of a​ 6-year-old client diagnosed with autism spectrum disorder​ (ASD). Which item in the health history should the nurse consider may have been a factor in the client developing​ ASD? A) Postterm birth B) Appropriate adaptation to new environments C) Childhood vaccinations D) Fetal alcohol syndrome

D ​Rationale: The ingestion of​ alcohol, tobacco, and toxic substances has been known to cause birth defects.​ Therefore, fetal alcohol syndrome could possibly be a factor in the development of ASD. Childhood vaccinations have not been proven to cause ASD. Appropriate adaptation to new environments and postterm birth have no link to ASD.

The mother of an​ 8-month-old infant is concerned that her​ infant, who weighed 8 pounds at​ birth, is now 18 pounds. The mother​ asks, "I'm afraid my baby is overweight for her​ age." How should the nurse​ respond? A) "At this​ stage, a child requires a more limited food​ intake, so your​ child's weight gain should​ stabilize." B) "Your child may be slightly​ underweight, and you should consult with a​ nutritionist." C) "You are correct. Your child is at risk for​ obesity, and you should consult with a​ nutritionist." D) "Your child's growth is on target because a​ baby's birth weight triples in the first​ year."

D ​Rationale: The​ child's growth is on target. An​ infant's birth weight doubles by about 5 months and triples in the first year. The child is not​ underweight, is not at risk for​ obesity, and does not require limited food intake

The nurse should recognize that in order for a child to inherit cystic fibrosis​ (CF), which parent must possess the transmembrane conductance regulator​ (CFTR) gene​ mutation? A) Neither parent B) Female parent with CFTR gene mutation C) Male parent D) Both parents

D ​Rationale: To have cystic​ fibrosis, a child must inherit one copy of the cystic fibrosis transmembrane conductance regulator​ (CFTR) gene mutation from each parent. People who have only one copy of a CFTR gene mutation do not have CF. They are called​ "CF carriers."

The nurse is developing a plan of care for a client diagnosed with autism spectrum disorder​ (ASD). Which nursing diagnosis is most appropriate for the nurse to​ include? A) Infection, Risk for B) Airway​ Clearance, Ineffective C) Macrocephaly, Risk for D) Communication: Verbal, Impaired

D ​Rationale: ​Communication: Verbal, Impaired is an appropriate nursing diagnosis for a client with ASD. ​Macrocephaly, Risk for is not a nursing diagnosis. The client with ASD is not at risk for infection or ineffective airway clearance.​ (NANDA-I ©2014)

The parents of a 16-month-old ask when they should begin toilet training. Which of the following should be included in a response by the nurse?Select all that apply.? A) When the child enters preschool B) When the child is able to sit alone without support C) When the child has a dry diaper throughout the night D) When the child can pull pants up and down E) When the child walks well

D, E Explanation: Children must have the physical and developmental capabilities to begin toilet training. They should be able to stand and walk well, pull pants up and down, recognize the urge to urinate or defecate, and be able to wait until they reach the potty chair.

A client with a history of substance abuse denies using any narcotics. Which expected outcome should the nurse select for this​ client? (Select all that​ apply.) A) The client will participate in group therapy. B) The client will verbalize the negative effects of alcohol on the body. C) The client will remain free from injury. D) The client will describe choices made that contributed to substance abuse E) The client will admit to having a problem with substance abuse.

D, E The client admitting to a problem with substance abuse and the client describing choices made that contributed to substance abuse are both expected outcomes for a client diagnosed with ​Denial, Ineffective. These expected outcomes demonstrate the​ client's willingness and ability to recognize substance abuse as a problem. The client remaining free of​ injury, the client verbalizing the negative effects of alcohol on the​ body, and the client participating in group therapy are not expected outcomes for a diagnosis of ​Denial, Ineffective. ​(NANDA-I ©2014)

The nurse is teaching the parents of a very young client newly diagnosed with​ attention-deficit/hyperactivity disorder​ (ADHD) regarding therapeutic interventions. Which intervention should the nurse encourage the parents to implement during study time at​ home? (Select all that​ apply.) A) Administer stimulant medication at least 30 minutes prior to studying. B) Give the child a snack to eat during study time. C) Allow the child as much screen time as he desires. D) Provide a​ clutter-free area to study. E) Reduce environmental stimuli such as music and television.

D, E ​Rationale: During study​ time, the client should have a​ quiet, clutter-free area to study and complete homework assignments. Giving the child a snack would provide a distraction during study​ time, so this should happen either before or after study time. Minimizing screen time is an important environmental control that should be implemented. Stimulant medications are administered first thing in the​ morning, not prior to tasks.

The nurse is planning care for a pregnant client with a substance abuse disorder. Which intervention should the nurse identify to address imbalanced nutrition in this​ client? (Select all that​ apply.) A) Educate on negative effects of substances on body. B) Educate on negative effects of substances on fetal health. C) Assess for signs of infection. D) Obtain daily weight. E) Monitor meal intake.

D, E ​Rationale: Weighing the client and monitoring meal intake are appropriate interventions for a client with a nutritional deficit. Assessment of signs of infection would be appropriate for a risk for infection. The client has a potential for enhanced knowledge when educated on the effects of substance use on the body and on fetal​ health, but they are not related to nutrition imbalances.

The nurse is teaching the family of a client diagnosed with autism spectrum disorder​ (ASD) about a​ gluten-free and​ casein-free diet. Which food should the nurse​ include? (Select all that​ apply.) A) Cheese B) Grilled salmon C) Soy milk D) Cornmeal E) Yogurt

B, C, D ​Rationale: A​ gluten-free and​ casein-free diet eliminates wheat and dairy products. Foods that support a​ gluten-free and​ casein-free diet include​ cornmeal, grilled​ salmon, and soy milk. Cheese and yogurt are​ casein-rich foods.​ Therefore, they should be avoided

Which intervention is an appropriate nonpharmacologic treatment for the nurse to include in the plan of care for a client with autism spectrum disorder​ (ASD)? (Select all that​ apply.) A) Encouraging parents not to vaccinate their children B) Creating an environment that is conducive to positive behavior management C) Establishing support for the parents and family D) Teaching the family about studies on complementary care E) Promoting enhanced communication

B, C, D, E ​Rationale: Children with ASD will benefit from the following nonpharmacologic treatment​ options: establishing support for the parents and​ family; creating an environment that is conducive to positive behavior​ management; promoting enhanced​ communication; and educating the family about studies on the use of complementary care. Discouraging parents from vaccinating their children is not an appropriate treatment option for children with ASD.

Which assessment finding should the nurse expect in a child with autism spectrum disorder​ (ASD)? (Select all that​ apply.) A) Stuttering B) Enchantment with rhythmic repetition of verse or song C) Use of the word you to represent I D) Reiteration of questions as opposed to answering them E) Echolalia

B, C, D, E ​Rationale: Echolalia​ (parroting a particular word or​ phrase), repetition of inquiries rather than responding to​ them, using you to represent ​I, and fascination with things that are lyrical in nature such as a song or verse are typical speech pattern abnormalities for children diagnosed with ASD. Stuttering is not a clinical manifestation associated with ASD.

The nurse is preparing a presentation on substance use disorders for a community group. Which risk factor should the nurse include that predisposes the development of a substance use​ disorder? (Select all that​ apply.) A) Divorce B) Loneliness C) Family history D) Low income E) Mental illness

B, C, E Rationale: Mental​ illness, loneliness, and family history are risk factors that might predispose a client to develop a substance use disorder. Having a low income or being divorced does not predispose a client to developing a substance use disorde

The grandparents of a 2½-year-old ask what would be an appropriate toy to buy their grandson. Which toy should the nurse recommend?Select all that apply.? A) A paint-by-number set B) A small tricycle C) A 54-piece puzzle D) A play telephone E) A musical mobile

B, D Explanation: Toddlers enjoy such toys as a play telephone, which allows them to practice imitative behaviors and fine motor skills. More complex puzzles, such as those with 54 pieces, are recommended for school-age children. Paint-by-number sets are recommended for school-aged children. Musical mobiles are appropriate for infants. Manipulation of toys such as a tricycle develops gross motor abilities in toddlers.

When assessing middle-aged adult clients in the community, what common disorder seen more in women than men would the nurse try to prevent through health promotion programs? A) Osteoarthritis B) Anemia C) Hyperlipidemia D) Coronary artery disease

B Explanation: After women reach menopause, the statistics change, and levels of hyperlipidemia increase to match those of men at this age. After women reach menopause, the statistics change, and levels of coronary artery disease increase to match those of men at this age. Women in the middle-adult age range often have a decreased intake of iron products, in addition to a gradual loss of red blood cells from menstruation. Therefore, at this age anemia is more common in women than men. Osteoarthritis is not a gender-based disorder but rather one of wear and tear on joints caused by lifestyle.

The mother of a neonate states she is concerned about her relationship with the infant. She says the baby goes to anyone and doesn't seem to care if she is present or not. The nurse explains that prior to developing a dependence on the mother, the infant must develop which of the following? A) Ritualistic behavior B) Object permanence C) Conservation D) Egocentrism

B Explanation: Object permanence is the knowledge that an object or person continues to exist when not seen, heard, or felt. The baby will not attach to a single person, even the mother, until he or she is aware of the mother's existence. Ritualistic behavior, egocentrism, and conservation do not address this phenomenon.

An​ 18-month-old client is suspected of having cerebral palsy​ (CP). Which test should the nurse expect to be prescribed to help diagnose this​ client? (Select all that​ apply.) A) Laboratory studies of protein levels in the bloodstream B) CT scan C) PET scan D) Electrocardiographic studies E) MRI

B,C,E Rationale: There is no specific diagnostic test for​ CP, but​ MRI, CT​ scan, and PET scan can be helpful in eliminating other organic brain​ disease, such as tumors or developmental issues. Electrocardiographic studies and laboratory studies are not used to diagnose CP.

The nurse is assessing an​ infant's growth and development. Which assessment finding is specific to the infant stage of growth and​ development? A) Jaw proportions change. B) Growth is associated with type and quality of feeding. C) Most growth takes place in long bones. D) The child requires a more limited food intake.

B Rationale: In the infant stage of​ development, growth is associated with type and quality of feeding.​ Toddlers, not​ infants, require less food intake. Most growth occurs in long bones in​ preschool-age children, not in infants. Jaw proportion changes do not occur during infancy.

The nurse should understand that the genetic defect of cystic fibrosis causes which change to the mucus​ secretions? A) They become yellow with pus. B) They become thick and sticky. C) They become thin and watery. D) They become bloody.

B Rationale: The genetic defect of cystic fibrosis causes mucus secretions to become thick and sticky. Cystic fibrosis involves the cellular entry of too much salt and not enough water. These sticky secretions block ducts and passageways in the​ body, including the lungs and pancreas.

A child is newly diagnosed with cerebral palsy​ (CP). For which type of cerebral palsy should the nurse most likely plan​ care? A) Mixed cerebral palsy B) Spastic cerebral palsy C) Dyskinetic cerebral palsy D) Ataxic cerebral palsy

B ​Rationale: About​ 80% of all cases of CP are classified as spastic. The other types of cerebral palsy are less common.

What would be the nurse's focus when conducting health-promotion activities for healthy adults in their twenties, based on knowledge of the highest risks during this period of life? A) Safety education for accident prevention B) Screenings for breast, cervical, uterine, and prostate cancers C) Chest x-rays for detection of lung cancer D) Bone density test for osteoporosis

A Explanation: Cancers for breast, uterus, cervical, or prostate are not the greatest risks for a 20-year-old; rather, these are of greater concern for the older adult. Cancers of the lung are not the greatest risks for a 20-year-old; this is of greater concern for the older adult. Bone density testing for osteoporosis is often not recommended for the female in her twenties. Most women will test for this near menopause. A healthy 20-year-old has the greatest risks related to lifestyle behaviors, such as multiple sexual partners, "on-the-edge" lifestyle (thrill seeking), haphazard dietary intake, speeding, and not sleeping enough.

When planning a menu for the older adult client, the nurse should limit which types of foods? A) Refined carbohydrates B) Low-fat dairy products C) Whole-grain products D) Alternate proteins

A Explanation: Low-fat dairy products are recommended to minimize complications of atherosclerosis and osteoporosis. Whole-grain products are recommended to minimize complications of constipation. Alternate proteins are recommended to minimize complications of atherosclerosis. Older adults develop a slower metabolic rate and often decrease their activity at the same time. By reducing intake of refined carbohydrates, the calorie count meets the needs of the body.

Which intervention is most appropriate for the nurse to include in the plan of care for a child with autism spectrum disorder​ (ASD)? A) Encouraging the​ client's family to bring in familiar objects from home B) Rearranging the hospital room until a comfortable arrangement is found C) Scheduling procedures for different times each day D) Putting the television on loud to provide stimulation for the client

A ​Rationale: Clients with ASD need structure and a predictable course of action. Bringing in familiar objects from home provides comfort for the client. It is important for the nurse to be oriented to the room and care should be taken not to relocate objects in the environment. Clients with ASD are sensitive to loud noises and bright​ lights, so the television should be turned off to minimize stimuli that may distress the client. Procedures should be scheduled for the same time to maintain predictability.

The nurse caring for an adult with cystic fibrosis​ (CF) should recognize which concern as being increasingly ​important? A) Fertility B) Nutritional supplementation C) Ongoing sweat testing D) Ability to take medication

A ​Rationale: Fertility is an increasing concern for adults with CF. Women with CF who receive adequate nutrition and have good lung function have pregnancy rates equal to those of the general population.​ However, due to a blockage or absence of the vas​ deferens, only about 2-​3% of men with CF are fertile.

A client is diagnosed with geriatric failure to thrive​ (GFTT). Which finding should the nurse use to justify this​ diagnosis? A) Weight loss of more than​ 5% of baseline body weight B) Weight loss of more than​ 15% of baseline body weight C) Increased social interaction D) Increased homeostasis

A ​Rationale: Geriatric failure to thrive​ (GFTT) is a condition in which older clients experience a weight loss of more than​ 5% of baseline body​ weight, decreased​ appetite, undernutrition and​ dehydration, depression, and cognitive and immune impairment. GFTT does not increase homeostasis. This health problem could lead to or be caused by social isolation. A weight loss of more than​ 15% of baseline body weight is severe malnutrition requiring medical intervention.

The mother of a​ 4-month-old client is concerned that the client may be developmentally delayed. Which finding should lead the nurse to suspect cerebral palsy​ (CP) in the​ infant? A) Hypotonia B) Head lag C) Follows objects 180 degrees D) Tonic neck reflex

A ​Rationale: Head​ lag, tonic neck​ reflex, and following objects 180 degrees are all normal for a​ 4-month-old infant. If head lag and tonic neck reflex persist beyond 6​ months, then they would be a concern and suggest CP. Hypotonia is not normal and could be a sign of CP.

An adult client with​ attention-deficit/hyperactivity disorder​ (ADHD) is being prescribed medication. About which medication should the nurse prepare teaching for this​ client? A) Atomoxetine​ (Strattera) B) Methylphenidate​ (Ritalin) C) Dextroamphetamine​ (Adderall) D) Guanfacine​ (Intuniv)

A ​Rationale: The nonstimulant medication atomoxetine​ (Strattera) is used for children over age 6​ years, adolescents, and adults to control the symptoms of ADHD. Stimulants like dextroamphetamine and methylphenidate are approved for use in​ adults; however, there is a higher risk of adverse effects on the cardiovascular system. There is no information about guanfacine use in adults.

The nurse anticipates that there is likely to be the highest risk for major medical complications in the older adult client based on which common problem? A) Taking over-the-counter meds with prescription meds B) Trouble following directions consistently and exactly C) Polypharmacy from multiple doctors that is not addressed among these doctors D) Sharing meds with family and friends

C Explanation: Although taking over-the-counter medications on one's own in combination with prescription meds can lead to problems, polypharmacy is a greater issue. Sharing medications could be an issue for some adults who want to assist others by providing medications that helped in their own cases. Having difficulty following directions consistently could lead to issues, but this risk is not greater than the risks inherent with polypharmacy. Polypharmacy is using multiple doctors and multiple pharmacies to get the health care needed, often from a variety of specialists. This could result in medication orders that interfere with or augment the response to other medications, or could have dangerous drug interactions.

An older adult client recovering from influenza has a poor appetite 3 weeks later and is losing weight. Which goal should the nurse identify for this​ client? A) Preventing infection B) Providing education about personal safety C) Gaining weight through improved nutrition D) Assessing individual and family coping mechanisms

C Rationale: For the older adult client with geriatric failure to thrive​ (GFTT), nursing care centers on weight gain and nutritional improvement. Preventing​ infection, coping​ mechanisms, and personal safety practices will not help improve GFTT.

A​ 6-year-old child with cerebral palsy​ (CP) new to a school district is experiencing severe rigidity and spasticity. What should the school nurse say to the​ parents? A) "Look into special schools for the​ handicapped." B) "Offer only​ low-carbohydrate, low-calorie foods to the​ child." C) ​"What exercises can we do during school to help with the​ rigidity?" D) ​"Discourage the use of a​ computer."

C ​Rationale: The child with CP most likely has been evaluated and treated by a physical therapist who developed a plan for tendon stretching and​ range-of-motion exercises to decrease the rigidity and spasticity. This plan should be shared with the school nurse. Most school districts do not require that children with physical disabilities such as those associated with CP attend alternative schools. Children with CP require​ high-calorie foods because of feeding difficulties associated with spasticity and hypotonia. Computers are encouraged to promote communication.

The Denver Developmental Screening Test has shown a 6-month-old infant is delayed in gross motor development. What activities by the nurse would best help the child reach the expected developmental level?Select all that apply.? A) Encouraging the child to stand B) Encouraging the child to hold a rattle C) Propping the child in a sitting position D) Pulling the child to a sitting position E) Talking to the child

C, D Explanation: It is too early to begin assistance with standing. Talking to the child promotes language development. Propping the child in a sitting position helps to develop self-righting behaviors. Handling a rattle involves fine-motor behavior. Pulling the child to a sitting position allows neck muscles to support the head and also aids with sitting.

he nurse is teaching the parents of a child with autism spectrum disorder​ (ASD) who is being treated with a​ gluten-free and​ casein-free diet. Which food should the nurse teach the parents to eliminate in the​ child's diet?​ (Select all that​ apply.) A) Beef B) Corn C) Grain D) Milk E) Cheese

C, D, E ​Rationale: Foods that should be avoided include grains and dairy​ products, such as milk and cheese. Corn and beef can be consumed when following a​ gluten-free and​ casein-free diet. Clients considering a​ gluten-free and​ casein-free diet should be referred for​ counseling, so as to be able to meet the​ child's nutritional needs.

A client is hospitalized for a substance abuse disorder. Which intervention should the nurse identify to promote safety for this​ client? (Select all that​ apply.) A) Obtain samples for drug analysis. B) Set limits to behavior. C) Discuss coping skills. D) Obtain a drug history. E) Encourage to verbalize fears.

C, E Rationale: Discussing coping skills and encouraging the client to verbalize fears are appropriate interventions for promoting healthy coping skills. Obtaining samples for drug​ analysis, setting limits to​ behavior, and obtaining a drug history do not pertain to the​ client's safety.

A mother brings her 15-month-old son to the clinic. During the nursing assessment, the mother makes the following comments. Which comment merits further investigation? A) "My son likes to eat mashed potatoes." B) "My son always takes his blanket with him." C) "My son cries at times when I leave him at his grandparents' house." D) "My son is not crawling yet."

D Explanation: It is a normal response for a 15-month-old to cry when left with others. Infants and toddlers are often attached to security items, such as a blanket. Infants crawl or pull their body along the floor using their arms by age 8 to 10 months, which is a growth and developmental milestone. An inability to crawl by age 15 months is an abnormal finding, and should be referred to the pediatrician for follow-up. Toddlers begin to display food preferences.

The pediatric nurse is a guest speaker for general health teaching in a prenatal class with young adults. The nurse would stress which factor that is most important to promote positive growth and development of the fetus? A) Exposure to secondary smoke B) Ethnic background C) Financial income D) Nutrition

D Explanation: Nutrition is the greatest influence on growth and development because diet supplies the nutrients needed to sustain physiological needs and for bodily growth, which then influences overall development. Insufficient income could indirectly affect growth and development, but this depends on how income is used in providing nutritious foods for the body. Second-hand smoke indirectly affects health. Ethnic background has significant influence on culturally based habits but not necessarily on biological growth and development.

The nurse is caring for a 7-year-old child scheduled for surgery in the morning. While conducting preoperative teaching, the nurse would choose which aid to enhance the child's learning about the perioperative experience? A) A visit from the surgeon B) Videotape C) Colorful brochure D) Doll or puppet

D Explanation: Videotapes are useful with explanations to adolescents. Brochures are useful with explanations to adolescents. The use of a doll or puppet may decrease a 7-year-old child's anxiety and fear if the nurse uses such aids to explain what is expected. A visit from the surgeon is informative primarily with the parents.