NCLEX EAQ Nursing 170 Adaptive Quizzing
What are the greatest risks for injury for an adolescent?
-Substance abuse -automobile accidents
The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client?
The child is developing a conscience.
The parents of a 6-month-old ask a nurse how to introduce their infant to pureed foods. How should the nurse respond?
"Introduce one food at a time every 4 to 7 days."
The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond?
"Maternal antibodies interfere with the development of active antibodies by the infant when immunized."
A couple at the prenatal clinic for a first visit tells the nurse that their 2-year-old child has just been found to have cystic fibrosis. They state there is no family history of this disorder. They ask the nurse about the chances of their having another child with cystic fibrosis. Knowing that this disorder has an autosomal-recessive mode of inheritance, how should the nurse respond?
"There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier."
How should a nurse respond to parents who are concerned about separation anxiety in their 15-month-old toddler?
"This is an expected developmental reaction."
A parent tells the nurse, "My 9-month-old doesn't have the same strong grasp that she had when she was born, and she's not startled by loud noises anymore." How should the nurse explain these changes in behavior?
"Those responses are replaced by voluntary activity around 5 months of age."
The clinic nurse is teaching the parents of a 3½-year-old child who is up to date on all vaccinations when it will be necessary to return to the clinic for the next set of vaccinations. Which statement indicates that the parents understand the teaching?
"We need to come back to the clinic in 1 year for more vaccinations."
An IV catheter is to be inserted into a 3-year-old toddler's peripheral vein. As local topical anesthetic is applied, the toddler starts to cry and asks whether the insertion is going to hurt. How should the nurse respond?
"Yes, it will hurt, but not for very long."
Which ages are the most critical for language development during the preschool stage of development?
-3 years -4 years
In which settings should the nurse prepare to administer developmental assessment for pediatric clients?
-Home -School -Hospital -Daycare Center Rationale: Pediatric developmental assessments are performed in many settings, including the home, school, hospital, and daycare center environments. It is unlikely that a pediatric developmental assessment would be performed in an assisted living center.
When preparing a child with asthma for discharge, what instructions must the nurse emphasize to the family?
-Limit allergens in the home -Continue the medications even if the child is asymptomatic.
At what age does the anterior fontanel of the skull close?
12 and 18 months
To which client should the nurse provide education regarding the pubertal growth spurt?
A 12-year-old school-age female client
A nurse encourages parents to have their toddler's eyes tested especially for monocular strabismus. What should the nurse explain may occur if the condition is not corrected early?
Amblyopia will progress in the weak eye.
The parents of a 6-week-old infant who was born without an immune system ask the nurse why their baby is still so healthy. What is the best response by the nurse?
Antibodies are passively received from the mother through the placenta and breast milk.
A new mother tells the nurse that her baby "spits up" after each formula feeding. The nurse teaches her how to position her newborn after feedings. During the next feeding the nurse notes that the mother is positioning the baby correctly. Why is the nurse observing this activity?
Confirm that learning has occurred
A nurse is observing hospitalized toddlers in the playroom. What does the nurse identify as their most important need?
Contact with their parents
A nurse is teaching a high school student about scoliosis treatment options. On what should the nurse focus?
Effect on body image
What is the best way for the nurse to promote the social development of a 9-month-old infant?
Engaging in peek-a-boo
A school nurse is teaching a group of teachers' aides about the cause of lead poisoning in children. What should be considered in terms of prevention?
Environmental factors are involved because lead is available for ingestion and inhalation.
A nurse in the daycare center is teaching several aides about the play behavior of 2-year-old toddlers. What is this type of play called?
Parallel
A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation?
Physical Therapy
The nurse encourages a client with Raynaud disease to stop smoking. Which primary goal is the nurse trying to achieve?
Prevent peripheral vasoconstriction
A 7-month-old infant is brought to the pediatric clinic for a well-child visit. The nurse assesses several of the infant's behaviors. What behavior is most unusual for an infant of this age?
Putting clothespins in a plastic bottle
What is the best approach for the nurse to use when preparing a preschooler for surgery?
Using a doll to demonstrate perioperative care
A nurse is evaluating a 3-year-old child's developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay?
Using a spoon effectively
A nurse instructs the parents of an adolescent with asthma how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed?
Using flat outdoor carpeting to cover hardwood floors
The nurse notes that a 4-year-old child is having difficulty relating to some of the children in the playroom. What does the nurse identify as the reason that this problem is not unexpected?
Exaggerating and boasting to impress others are typical behaviors of preschoolers.
What is the average height of a four-year-old child?
3 feet, 4.5 inches (103 cm)
After the client gives birth, her vital signs are temperature 99.3° F (37.4° C); pulse 80 beats/min, regular and strong; respirations 16/min, slow and even; and blood pressure 148/92 mm Hg. Which vital sign should the nurse check more frequently?
Blood pressure
How can a school nurse help determine a young child's readiness to learn?
By assessing the child's vision and hearing Rationale: Vision and hearing are vital to the child's ability to learn because they provide pathways for stimuli to reach and be interpreted by the brain. Neither psychological nor intelligence testing is necessary for all children. Although important in the learning process, ensuring that the teacher understands the child's needs and confirming that the parents understand the importance of homework are not related to a child's readiness to learn.
What is the best way for a nurse to interact with a 3-year-old child sitting in the waiting room of the pediatric clinic?
By walking into the waiting room to greet the child
A 12-year-old child is to be bedridden at home for several weeks after orthopedic surgery. What activity should the nurse encourage the parents to plan?
Continuing schoolwork
The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action?
Data collection
The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say that this daily information is important in determining?
Fluid retention
Which hormone aids in regulating intestinal calcium and phosphorous absorption?
Glucocorticoids
A 4-year-old child with acute lymphocytic leukemia (ALL) is to undergo bone marrow aspiration. While involving the child in therapeutic play before the procedure, what should the nurse help him understand?
He did nothing to cause his current illness.
A nurse is trying to soothe a 2-month-old infant who is crying. What is the best way to soothe a young infant?
Holding and rocking the infant in a quiet room
What is the most major cause of acne in adolescent women?
Hormonal Imbalance
A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include?
Importance of meticulous oral hygiene
According to the nurse describing Erikson's theory, in which stage does a preschooler start to pretend?
Initiative versus guilt stage Rationale: The initiative versus guilt stage is the third stage of Erikson's theory. During this stage, children like to pretend and try out new roles. Integrity versus despair is the eighth stage of Erikson's theory. At this stage, many older adults view their lives with a sense of satisfaction. The development of self-care activities in a toddler occurs at the stage of autonomy versus sense of shame and doubt. This is the second stage of Erikson's theory. Middle-aged adults achieve success at the stage of generativity versus self-absorption and stagnation. Individuals contribute to future generations through parenthood, teaching, and community involvement.
A pregnant woman asks the nurse when she may expect her baby to be born. She tells the nurse that her last menstrual period began on April 14. According to Nägele's rule, what is the client's expected date of birth (EDB)?
January 21 Rationale: To use Naegele's rule to calculate the EDB, subtract 3 months and add 7 days to the date of the last menstrual period. January 7 is too early. February 1 is too late, as is February 7.
The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age?
Maternal antibodies provide immunity for about 1 year.
A 55-year-old client reports cessation of menstrual periods. Which term best describes the client's condition?
Menopause
The parent of a 3-month-old infant asks the nurse about selecting toys for the infant. Which toy should the nurse tell the parent is most appropriate at this age?
Metallic mirror
A 6-year-old child treated for acute glomerulonephritis has improved and is soon to be discharged. What should the nurse plan to offer the parents in preparation for the discharge?
Samples of no-salt-added diets for the child to continue at home Rationale: Foods high in sodium and salty treats are usually limited to control or prevent edema and hypertension until the child is asymptomatic. The child should not be kept active for long periods because rest is needed; the child usually does not need a long convalescence. Glomerulonephritis usually does not cause such severe kidney damage that a kidney transplant is necessary. The mother should contact the healthcare provider, not the nurse on the unit, for follow-up care.
A nurse is planning to foster independence in a group of 4-year-old children. What self-care skill does the nurse expect 4-year-olds to be capable of performing?
Putting on a shirt and buttoning it
Which feature is characteristic of a risk nursing diagnosis?
The diagnosis does not have related factors.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care?
The disease process and breathing exercises