Nursing Chapter 17
The nurse is caring for a patient that is actively trying to conceive a child but continues to drink alcohol. The patient states that she'll stop drinking once she is pregnant. What is the most appropriate response by the nurse? a."Abstaining is best since most fetal development occurs before you realize you are pregnant." b."Small amounts of alcohol are safe at any time during pregnancy." c."Things will be okay if you quit drinking alcohol once you know you are pregnant." d."Alcohol use should be avoided early in pregnancy but is acceptable past week 20."
a."Abstaining is best since most fetal development occurs before you realize you are pregnant." Rationale: Rapid development occurs before many women know that they are pregnant, making alcohol consumption unsafe at any time during pregnancy.
The nurse is asked by the parent of a pediatric patient to explain the difference between growth and development. Which response by the nurse is best? a."Growth is physical while development relates to physical, emotional, and cognitive function." b."There is no difference between the two since they occur simultaneously." c."Development refers to musculoskeletal and nervous system abilities and growth is a change in height and weight." d."Both refer to an increase in abilities and functions of the child that occur sequentially over time."
a."Growth is physical while development relates to physical, emotional, and cognitive function." Rationale: Growth relates to physical changes in height and weight. Development refers to changes in ability across several dimensions such as physical, emotional, and cognitive. Stating that the two are not different does not show understanding of this difference. Development is not related strictly to changes in specific body systems. Although both refer to increases in abilities and functioning over time, this answer is too vague to give the parent useful information.
A nurse is assessing a 12 month old at a well-baby visit. For what developmental milestones does the nurse assess this child? (Select all that apply.) a.Attempting to walk with help b.Transferring objects from one hand to the other c.Ability to roll around on the floor holding a bottle independently d.Searching for objects that are out of sight e.Moving from lying on abdomen to sitting unassisted
a.Attempting to walk with help d.Searching for objects that are out of sight e.Moving from lying on abdomen to sitting unassisted Rationale: A 12 month old should be attempting to walk with help, hold a bottle independently and move from lying on abdomen to sitting up unassisted. Transferring objects from one hand to the other and rolling from front to back are milestones seen around 7 months of age and holding a bottle independently occurs at 4 to 6 months.
A nurse is planning a community education event for parents on the topic of school-aged children and the risks of too much social media time. What topics should the nurse plan to include? (Select all that apply.) a.Increased bullying b.Decreased physical activity c.Decreased understanding of spatial relationships d.Weight loss and malnutrition e.Increased aggressiveness
a.Increased bullying b.Decreased physical activity e.Increased aggressiveness Rationale: Some of the risks associated with social media include bullying, decreased physical activity with resultant obesity, and aggressiveness.
A preschool-aged child got into the cookie jar and ate several cookies before dinner. When confronted by the parent, the child responds, "My pet horse ate them." What does the nurse teach the parents about this response? a.It is normal for children to have imaginary friends at this age. b.This vivid imagination will lead the child to misbehave later on. c.Lying is disobedient and should be punished consistently. d.The child is obviously afraid of the parents' response.
a.It is normal for children to have imaginary friends at this age. Rationale: It is common for toddlers to have imaginary friends. They are especially important in allowing the child to express something unpleasant. The other responses are not appropriate.
The nurse is teaching parents about actions to assist in developing a critical skill in the concrete operations phase of Piaget's developmental theory. What activities does the nurse suggest the parents participate with their child in? (Select all that apply.) a.Separating a collection of toy horses into functions each type performs. b.Exploring a space and astronomy museum and planetarium together. c.Making a scrapbook of leaves sorted by color or type of tree. d.Having the child explore how common objects can be used for different purposes. e.Asking the child to describe an event from several different points of view.
a.Separating a collection of toy horses into functions each type performs. c.Making a scrapbook of leaves sorted by color or type of tree. Rationale: In the concrete operational stage of Piaget's theory, seriation is an important task. This task includes separating or sorting objects using specific criteria. Separating toy horses by functions and arranging a leaf album by color or tree type are examples of seriation. Exploring museums does not contribute to seriation. Learning how objects can be used for unusual purposes and describing other points of view are part of the formal operations stage.
A high-school nurse is planning an educational presentation for juniors. What activities are most appropriate for the nurse's plan to include? (Select all that apply.) a.Video showing the aftermath of a drunk driving car crash b.Confidential depression and suicide risk assessment c.Same-age speaker sharing her story about the impact of HIV disease d.Charts and graphs showing the physical changes of puberty e.Bicycle helmet fitting station to see if child has outgrown the helmet
a.Video showing the aftermath of a drunk driving car crash b.Confidential depression and suicide risk assessment c.Same-age speaker sharing her story about the impact of HIV disease d.Charts and graphs showing the physical changes of puberty Rationale: Adolescents need education on drinking and driving, suicide and depression, safer sexual practices, and physical changes that occur during puberty. A bicycle helmet fitting station would not be a priority for this age-group.
The parents of a 4 year old express concern that the child is wearing the same size clothing as she did last year. What action by the nurse is most appropriate? a.Weigh and measure the child and compare with last visit. b.Reassure parents that their child is growing normally. c.Assess the child's eating and activity patterns. d.Encourage the parents to provide the child a multivitamin.
a.Weigh and measure the child and compare with last visit. Rationale: Physical growth slows during the preschool years, with most children only gaining about 5 lb and 2 1/2 to 3 inches a year. The nurse should weigh and measure the child and compare the readings to those taken at the last visit. Showing the parents these results and educating them on expected growth will reassure them. Simply telling the parents their child is normal does not provide objective information and is dismissive of their concern. The nurse should assess each child's eating and activity habits. The child may or may not need a vitamin. This can be discussed with the provider.
A nurse is providing anticipatory guidance to a new mother about the Erikson stage of trust versus mistrust. What education should the nurse provide to the mother to help her child successfully master this stage? a. Consistently provide your child with food and attention. b. Ensure someone is able to feed your child on a schedule. c. Allow unrestricted crawling and exploring as the child develops. d. Provide firm guidelines for behavior and activities.
a.\Consistently provide your child with food and attention. Rationale: The most important item needed for a child to master this stage of development is a consistent caregiver who provides food and attention. If the caregiver is inconsistent or unable to meet these needs, the child will develop mistrust of those around him. Ensuring that someone feeds the child is not providing consistency. Allowing exploration within limits (setting boundaries) is important to master initiative versus shame and doubt.
The perinatal clinic nurse is going to teach a woman from a culture unfamiliar to the nurse about child-rearing practices. What action by the nurse is best before planning the education? a.Ensure the availability of written material to give the woman. b.Assess what practices are important to her cultural group. c.Determine if the woman is the primary family decision maker. d.Refer the woman to a prenatal educational class.
b.Assess what practices are important to her cultural group. Rationale: The nurse must ensure he/she has a solid understanding of important child-rearing concepts in the woman's culture or risk that any teaching done will be irrelevant and perhaps in opposition to important beliefs. Since the nurse is unfamiliar with this culture, the first step is to assess. Written material is helpful if the patient can read and comprehend it. It would be important to determine if the woman is the decision maker, but this is not as much of a priority as learning about the culture. Referring the woman to an educational group may or may not be helpful.
A home health care nurse is making a well-baby visit to the home of a new mother who has an infant. What assessment finding leads the nurse to provide further anticipatory guidance and teaching to the mother? a.Mother states she does not breastfeed but uses a recommended formula. b.Crib has colorful blankets and pillows for the baby to cuddle. c.A mobile is hanging well above the crib playing soft music. d.Several rattles and plush toys are available in different textures.
b.Crib has colorful blankets and pillows for the baby to cuddle. Rationale: Objects such as pillows and blankets pose a suffocation hazard to infants and should be kept out of cribs. The other items are appropriate for a newborn.
A home health care nurse notes a parent becoming irritated when his toddler repeatedly throws his rattle from the high chair to the floor. What action by the nurse is most appropriate? a.Teach the parent about age-appropriate discipline. b.Educate the parent on age-appropriate behaviors. c.Tell the parent to stop giving the rattle back to the child. d.Assess the child for signs of abuse or neglect.
b.Educate the parent on age-appropriate behaviors. Rationale: Throwing an object down to watch someone else pick it up is a typical behavior for this age-group. The nurse should teach the parent about how this behavior relates to toddler growth and development. The other actions are not appropriate in this situation.
A father expresses frustration that his school-aged child is suddenly "sick all the time." What action by the nurse is best? a.Encourage the father to give the child a multivitamin each day. b.Explain that illness is frequent in this age-group because of exposure to others. c.Encourage the father to discuss testing the child's immunity with the provider. d.Make sure the parents are washing their hands frequently in the home.
b.Explain that illness is frequent in this age-group because of exposure to others. Rationale: Children in this age-group tend to have a higher incidence of minor illnesses because of exposure to others. The nurse can reassure the father by explaining this. No other action is needed at this point.
A pregnant woman in her second trimester is scheduled for quad testing. What conditions does the nurse explain are screened for in this assessment? (Select all that apply.) a.Blood clotting abnormalities b.Neural tube defects c.Heart abnormalities d.Trisomy 18 e.Trisomy 21
b.Neural tube defects d.Trisomy 18 e.Trisomy 21 Rationale: Quad testing includes assessing for neural tube defects, trisomy 18, and trisomy 21 (Down syndrome). It does not screen for heart or blood-clotting problems.
The nurse is collecting a history from the parents of a 4-year-old female at a well-child visit. The parents express concern that they often find their daughter performing what appears to be masturbation. The nurse offers reassurance by explaining which stage of development according to Freud? a.Oral b.Phallic c.Anal d.Latency
b.Phallic Rationale: The phallic stage occurs between the ages of 3 and 6 years, and pleasure centers on the child's discovery that self-stimulation is enjoyable. The oral stage is seen in infants where pleasure centers around the mouth and putting things in the mouth. The Anal stage occurs between 18 months and 3 years of age and is when tension and release of tension occur through anal elimination. The latency stage occurs between the ages of 6 years and puberty during which interest in sexuality is repressed.
A nurse is assessing an adolescent female who began menstruating 2 years ago. She has grown 1/2 inch in the last 2 years but has not gained any weight. What action by the nurse is most appropriate? a.Ask the teen to provide a 24-hour diet recall. b.Talk to the teen about healthy dietary practices. c.Reassure the teen she will have a growth spurt soon. d.Collaborate with the provider for endocrine testing.
b.Talk to the teen about healthy dietary practices. Rationale: During the adolescent growth spurt, teens achieve approximately 20% to 25% of their final height. This occurs during the time span ending about 2 years after the onset of menses. Since this teen has already reached that mark with little growth, the nurse should assess the teen's knowledge and practice of healthy eating. Poor eating habits are common with this age-group. A 24-hour diet recall can be utilized but the nurse's assessment should encompass more than just the recall. The teen most likely will not have another growth spurt later. Endocrine testing is not warranted at this point.
The nurse is conducting a home visit on a newborn. What observation would require the nurse to provide further education? a.The caregiver warms the bottle and tests heat on the inside of the wrist. b.The parents state the infant is sleeping with them until they buy a crib. c.One parent states that when the child gets frustrating, the other parent takes over. d.Caregivers consistently wash their hands before holding the baby.
b.The parents state the infant is sleeping with them until they buy a crib. Rationale: Infants should not sleep in the same bed as their parents because of the risk of suffocation. The other actions are appropriate.
To help a hospitalized infant master the tasks in Erikson's stage of Trust versus Mistrust, which action by the nurse is best? a.Provide calming music during quiet time so the infant can sleep. b.Give the family food vouchers for the hospital cafeteria. c.Arrange to have a cot or small bed placed in the infant's room. d.Do not allow unlicensed assistive personnel to care for the infant.
c.Arrange to have a cot or small bed placed in the infant's room. Rationale: Caregiver consistency is vital to accomplishing this task. The nurse should provide the parent(s) a comfortable place to stay in the infant's room. Giving food vouchers is also a good intervention, but not as important as ensuring the parent(s) can stay with the child. Calming music is appropriate for a child this age but does not help the child master tasks in this phase. Sleep is important for any hospitalized patient but is unrelated to mastering the tasks in this phase.
A nurse assesses a 4-month-old infant and notes the baby does not follow a moving object with her eyes. What action by the nurse is best? a.Document the findings and continue the assessment. b.Refer the child and parent to a pediatric neurologist. c.Assess the child for other age-appropriate behaviors. d.Assess the child for signs of child abuse or neglect.
c.Assess the child for other age-appropriate behaviors. Rationale: A 3-month-old child should be able to follow a moving object with his or her eyes. However, one single abnormal assessment finding does not necessarily mean that the child has a growth and developmental delay. The nurse should assess for other age-appropriate behaviors. Documentation should occur but is not the priority action at this point. A referral is not warranted nor is assessing for child abuse based on the data.
A parent is concerned that her 16 year old is spending most of his time away from the family in his room and does not want to be involved in family activities he used to enjoy. What action by the nurse is best? a.Reassure the parent the teen is exerting independence. b.Ask the parent about the teen's friends and activities. c.Assess the teen for depression and possible suicide risk. d.Refer the family to the community depression support group.
c.Assess the teen for depression and possible suicide risk. Rationale: Teens typically begin to withdraw from the family to maintain privacy and exert independence, so this alone is not concerning. However, since the teen is not participating in activities he once enjoyed, the nurse should conduct a depression assessment. If the teen is depressed, the nurse should assess his suicide risk. If these screenings are normal, the nurse can reassure the parent. The teen himself is the best source of information about friends and activities, although the parent can be a good secondary source. A referral is not warranted without further assessment.
The pediatric nurse is treating a patient who has questions about safer sexual practices. The patient states, "I think I should wait until marriage to be sexually active because I'm not sure sex is OK outside of marriage." The nurse understands the student is acting with which component of Freud's theory? a.Id b.Ego c.Superego d.Anal
c.Superego Rationale: The superego is the structure that houses the moral branch of personality. The Id acts strictly on instinct without consideration of reality. The Ego is partly conscious but does not consider right from wrong. Freud's theory contains the "anal phase."
A toddler has been hospitalized. The parents become upset when the toddler starts wetting his bed, saying that he has been potty trained for some time now. What response by the nurse is best? a."Don't worry, this behavior will stop when he gets home." b."Maybe he has a urinary tract infection; I'll get a urine sample." c."I can call the Child Life Specialist for diversionary activities." d."It is common for kids in the hospital to regress to earlier behaviors."
d."It is common for kids in the hospital to regress to earlier behaviors." Rationale: The stress of hospitalization often causes toddlers to regress in their behaviors, and the nurse should provide this information to the parents. Stating that the behavior will stop, although accurate, does not provide an explanation. There is no need for a urine sample. Using Child Life is always a good idea for hospitalized children but is not related to the question.
A nurse is conducting a preschool screening in the community. Which child would the nurse refer for further assessment? a.A 4 year old who throws a ball over-handed but better under-handed. b.A 4 year old who can skip across the room after being shown how. c.A 5 year old who is able to ride a bicycle with training wheels. d.A 5 year old who is unable to ride a tricycle without falling.
d.A 5 year old who is unable to ride a tricycle without falling. Rationale: A 3 year old should be able to ride a tricycle, so a 5 year old unable to perform this task needs further assessment. The other activities are appropriate for each child's age.
A school-aged child is scheduled for a minor procedure and is very nervous. What response by the nurse is best? a.Reassure the child the procedure is too minor to worry about. b.Read the child a pamphlet about what to expect during the procedure. c.Tell the child you will have the provider "put her to sleep" during the procedure. d.Explain the procedure and what to expect in simple terms.
d.Explain the procedure and what to expect in simple terms. Rationale: School-aged children benefit from simple explanations they can understand. Just telling the child not to worry is dismissive of the child's concerns. A school-aged child may not be able to read and/or understand a written pamphlet. Using phrases such as "put you to sleep" should be avoided since they can be misinterpreted.
The home health care nurse is visiting a family with a 3 year old to observe a meal. The parent gives the child a plate with 1/2 cup of pureed meat. What action by the nurse is best? a.Document how well the child eats the serving of meat. b.Inquire if the child still drinks from a bottle between meals. c.Ask the parents what they serve the child for snacks. d.Provide teaching on the appropriate serving size for this child.
d.Provide teaching on the appropriate serving size for this child. Rationale: An appropriate serving size is 1 tablespoon per year of age, so an appropriate amount of meat for this child is 3 tablespoons, not 1/2 cup (which is 8 tablespoons). The nurse should provide more education to the family. The other options are appropriate but are not directly related to the serving size of meat.