self assessment 1-5
The parents ask what they should do about his upcoming measles, mumps, and rubella (MMR) vaccine. Which response from the nurse is correct?
"Postpone the immunization for at least 11 months."
The parents ask what they can do to calm their infant because he is very irritable while the fever is high. What explanation by the nurse is most accurate?
"The irritability is part of the disease, and we'll try to keep him as comfortable as possible."
The child's mother asks about her son's dependence on large doses of pain medication and whether it will cause addiction later in life. What response by the nurse is most appropriate?
"The risk for addiction is extremely low. The child would not want to take this medication if there was no pain."
At what age would the nurse expect an infant to be able to say "mama" and "dada" with meaning?
10 months
By what age should the nurse expect that an infant will be able to pull to a standing position?
11-12 months
At what age is it safe to give infants whole milk instead of commercial infant formula?
12 months
The nurse should expect the apical heart rate of a stabilized neonate to be in which of the following ranges?
120-140 bpm
At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?
2 months
At about what age does an infant start to recognize familiar faces and objects, such as own hand?
3 months
At what age do most infants begin to fear strangers?
6 months
At what age can most infants sit steadily unsupported?
8 months
The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. The nurse's best response is which of the following?
Babies need comforting and cuddling. Meeting these needs will not spoil him
The child's pain management is of great concern to his mother. What information about this child should the nurse take into account when providing medication for pain?
Children with neurologic disorders, such as autism, are at greater risk than other children for undertreatment of pain.
Which of the following is true concerning the development of autonomy during adolescence?
Conformity to both parents and peers gradually declines toward the end of adolescence
What pain scale would be most appropriate for the nurse to use for a four year old child?
FLACC
Which of the following is the most appropriate recommendation for relief of teething pain?
Give child a frozen teething ring to relieve inflammation
What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age?
Give large push-pull toys for kinetic stimulation
The child has patient-controlled analgesia (PCA) of morphine with an 8-minute lockout. Teaching by the nurse has been effective if what behavior is seen in this child?
He pushes the button on the PCA whenever he wants.
When discussing development and play activities with the parent of a 2-month-old boy. Which of the following statements by the parent would indicate a correct understanding of the teaching?
I can use a music box and soft mobiles as appropriate play activities for my baby
The infant has not responded to the initial therapy and continues to have a high fever. What therapy would the nurse expect to administer to this infant?
Intravenous gamma globulin (IVIG)
Initial treatment with intravenous antibiotics has not decreased the fever. What therapy would the nurse expect to administer?
Intravenous gamma globulin (IVIG) and aspirin therapy
A 4-year-old child tells the nurse that she doesn't want another blood sample drawn because "I need all of my insides and I don't want anyone taking them out." Which of the following is the nurse's best interpretation of this?
Preschoolers have poorly defined sense of skin properties
A boy age 4 1/2 years has been having increasingly frequent angry outbursts in preschool. He is aggressive toward the other children and the teachers. This behavior has been a problem for approximately 8 to 10 weeks. His parent asks the nurse for advice. Which of the following is the most appropriate intervention?
Refer the child for a professional psychosocial assessment
The parents of a newborn say that their toddler "hates the baby. . . . He suggested that we put him in the trash can so the trash truck could take him away." The nurse's best reply is which of the following?
That is a normal response to the birth of a sibling. Let's look at ways to deal with this.
Although a 14-month-old girl received a shock from an electrical outlet recently, her parent finds her about to place a paper clip in another outlet. Which of the following is the best interpretation of this behavior?
This is typical behavior because of inability to transfer knowledge to new situations
Which of the following statements is correct about toilet training?
Wanting to please the parent helps motivate the child to use the toilet
The psychosocial developmental tasks of toddlerhood include which of the following?
ability to delay gratification
A toddler, age 16 months, falls down a few stairs. He gets up and "scolds" the stairs as if they caused him to fall. This is an example of which of the following?
animisim
Adolescents often do not use reasoned decision making when issues such as substance abuse and sexual behavior are involved. This is because they:
are dealing with issues that are stressful and emotionally laden
Which of the following types of play is most typical of the preschool period?
associative
The developmental task with which the child of 15 to 30 months is likely to be struggling is a sense of what?
autonomy
Steven's parents ask what causes epiglottitis. Based on the nurse's knowledge of epiglottitis, the most appropriate response is
bacterial, usually Haemophilus influenzae.
Which of the following is most descriptive of the spiritual development of the older adolescent?
beliefs become more abstract
A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is which of the following?
benign and transient
The newborn with severe jaundice is at risk for developing which of the following?
brain damage
In girls the initial indication of puberty is which of the following?
breast development
Instructions for using the MDI include to
breathe medication in slowly
The nurse is caring for a full-term infant who was born after an uneventful pregnancy and delivery. The infant's blood glucose level is 36 mg/dl. Which of the following interventions should the nurse take?
bring infant to mother and initiate breast feeding
Which of the following is the most common form of child maltreatment?
child neglect
A 4-year-old boy is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was "bad." Which of the following is the nurse's best interpretation of this comment?
common at this age
Which of the following is a central factor responsible for respiratory distress syndrome in the newborn?
deficient sufactant production
Kimberly needs instructions about using a metered-dose inhaler (MDI). The nurse should explain that the MDI is used to
distributes medication directly into airways
An infant, age 6 months, has six teeth. The nurse should recognize that this is which of the following?
earlier than expected truth eruption
Which of the following interventions may decrease the incidence of physiologic jaundice in a healthy full-term infant?
early and frequent feedings
The mother of a 3-month-old breast-fed infant asks about giving her baby water because it is summer and very warm. The nurse should tell her that:
fluids in addition are not needed
According to Piaget, adolescents tend to be in which stage of cognitive development?
formal operational thought
Which of the following characteristics best describes the fine motor skills of an infant at age 5 months?
grasp object voluntarily
Rh hemolytic disease is suspected in a mother's second baby, a son. Which of the following factors is important in understanding how this could develop?
her first child was RH positive
According to Erikson, the psychosocial task of adolescence is developing which of the following?
identity
The nurse should anticipate that the first treatment for epiglottitis will be
intubation
In terms of cognitive development, the 5-year-old child would be expected to do which of the following?
magical thinking
Which of the following terms is used to describe the newborn's first stool?
meconium
Parents tell the nurse they found their 3-year-old daughter and a male cousin of the same age inspecting each other closely as they used the bathroom. Which of the following is the most appropriate recommendation for the nurse to make?
neither condone or condemn
The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. The nurse should recommend which of the following?
never thaw or heat in microwave
A parent of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse's best interpretation of this behavior is which of the following?
normal behavior
The nurse is interviewing the father of a 10-month-old. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says "no" firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father that the child:
old enough to understand "no"
During a well-child visit the father of a 4-year-old boy tells the nurse that he is not sure if his son is ready for kindergarten. The boy's birthday is close to the cut-off date, and he has not attended preschool. Which of the following is the nurse's best recommendation
perform developmental screening
Which of the following is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?
playing peek a boo
Girls experience an increase in weight and fat deposition during puberty. Nursing considerations related to this include which of the following?
reassurance change is normal
Epinephrine is ordered to be given subcutaneously. The purpose of epinephrine is to
relieve bronchospasm
A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. Which of the following is the most appropriate recommendation?
remain close by but without eye contact
The physician orders a lateral neck x-ray film. The most important nursing action related to this is to
request portable x-ray film be taken in the emergency department.
According to Piaget, the 6-month-old infant would be in what developmental stage?
secondary circular reactions
Which one of the following dysfunctional speech patterns is a normal characteristic of the language development of a preschool child?
stammering
In about 1 week a stable preterm infant will be discharged. The nurse should place the infant in which of the following positions for sleep?
supine
Which of the following characteristics best describes the language skills of a 3-year-old child?
talks whether anyone is listening
A 17-month-old child would be expected to be in what stage, according to Piaget?
tertiary circular reaction
In boys the initial indication of puberty is which of the following?
testicular enlargement
In terms of gross motor development, what would the nurse expect an infant age 5 months to do?
turns from abdomen to back
During the 2-month well-child check-up the nurse expects the infant to respond to sound in the following manner:
turns head to side when sound is at ear
The grayish white, cheeselike substance that covers the newborn's skin is:
vernix caseosa
Which of the following characteristics best describes the gross motor skills of a 24-month-old child?
walks up and down stairs
The parents of a 7-year-old boy tell the nurse that lately he has been cruel to their family pets and actually caused physical harm. The nurse's recommendations should be based on knowledge that this is:
warning sign of serious problem