Developmental Stage
A nurse has provided information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further instructions?
"I should have my child sit on the potty until my child urinates." Rationale: The mother should wait until the child is 24 to 30 months old because this makes the task of toilet training considerably easier. Toddlers of this age are less negative and usually are more willing to control their sphincters to please their parents.
A nursing student is asked to describe the corpus of the uterus. Which response by the student indicates an understanding of the anatomy of the uterus?
Answer: "It is the uppermost part of the uterus." Rationale: The uterus has three divisions, the corpus, isthmus, and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus.
Montgomery's tubercles
Answer: Montgomery's tubercles are sebaceous glands in the areola Rationale: hey are inactive and not obvious except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft. Within each breast are lobes of glandular tissue that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk.
Which of the following developmental stages is Jean Piaget's first stage of cognitive development?
Answer: Sensorimotor Rationale: Jean Piaget's first stage of cognitive development is the sensorimotor stage (birth to 2 years). The preoperational stage is the second stage (2 to 7 years of age).
An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity?
Answer: Decreased lean body mass and glomerular filtration rate Rationale: The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate.
A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is about: MENSTRUAL CYCLE
Answer: Menstrual Cycle---28 days Rationale: The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. Significant deviations from the 28-day cycle are associated with reduced fertility. The first day of the menstrual period is counted as day 1 of the woman's cycle.
A nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which of the following is the most appropriate activity for this child?
Answer: A puzzle Rationale: In the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games.
When reinforcing appropriate developmental skills interventions for a 1-year-old child who was born 2 months premature, the nurse would plan to encourage the parents to support the child to do which of the following?
Answer: Sit independently. Rationale: For premature infants, calculate the developmental age by deducting the time of prematurity from the age of the child until reaching the age of 2 years.
A nurse is caring for a 14-year-old boy who is hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?
Answer: Let the child wear his own clothing when friends visit. Rationale: Adolescents need to identify with their peers and have a strong need to belong to a group. They like to dress like the group and wear similar hairstyles. Because Crutchfield traction uses skeletal pins, hair dye is not appropriate. The boy should be allowed to wear his own clothes to feel a sense of belonging to the group.
Progesterone
Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.
According to Kohlberg's theory of moral development, at the preconventional level, moral development is thought to be motivated by which of the following?
Answer: Punishment and reward Rationale: morals are thought to be motivated by punishment and reward. If the child is obedient and not punished, then he or she is being moral. The child sees actions as either good or bad. If the child's actions are good, then the child is praised. If the child's actions are bad, then the child is punished.
A nurse is assisting in conducting a teaching session with a group of adolescents. The nurse tells the adolescents that the primary hormone that induces the growth of pubic and axillary hair at puberty is:
Answer: Testosterone Rationale: Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.
A nurse is caring for a hospitalized 5-year-old client. The nurse would recognize that which of the following is normal for this child in this developmental stage?
Answer: The child demonstrates egocentrism. Rationale: A 5-year-old child is in Jean Piaget's preoperational stage of egocentrism.
Autonomy vs. shame and doubt
Autonomy vs. shame and doubt occurs during toddlerhood (early childhood, 18 months to 3 years).
OXYTOCIN
Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding.
A nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother which of the following? Select all that apply.
- "The child should not be forced to sit on the potty for long periods." - "The ability of the child to remove clothing is a sign of physical readiness." - "Waiting until the child is 24 to 30 months old makes the task considerably easier." - "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents." Rationale: Waiting until the child is 24 to 30 months old makes the task considerably easier because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents.
The parent of a 16-year-old child tells the nurse that she is concerned because the child sleeps until noon every weekend and whenever there is a day off from school. Which of the following is the appropriate nursing response?
Answer: "Adolescents love to sleep late in the morning." Rationale: The sleep patterns of the adolescent vary according to individual needs. Adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school.
The parent of an 8-year-old child tells the nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. The appropriate nursing response would be which of the following?
Answer: "At this age, the child is developing his or her own personality." Rationale:According to Erikson, from the ages of 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents.
The nurse evaluates that the older client needs teaching on how to promote sleep when the client states which of the following?
Answer: "I drink hot chocolate before bedtime." Rationale: Many nonpharmacological sleep aids can be used to influence sleep. The client should avoid caffeinated beverages and stimulants (e.g., tea, cola, chocolate) and foods that contain tyrosine (e.g., cheddar cheese). The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day
A nurse is evaluating the developmental level of a 2-year-old child. Which of the following does the nurse expect to observe in this child?
Answer: Holds a cup in one hand Rationale: By age 2 years, the child can hold a cup in one hand and use a spoon well.
Industry vs. inferiority
Industry vs. inferiority occurs during SCHOOL-AGE years (6 to 12 years).
Kohlberg's theory
Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal moralit
Mittelschmerz
Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation.
A nurse is reviewing the health record of a client who is suspected of having mittelschmerz. Which of the following should the nurse expect to note documented in the client's record?
Sharp pain located on the right side of the pelvis
Function of the ovaries
The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle.
Trust vs. mistrust characterizes
Trust vs. mistrust characterizes the stage of infancy
initiative vs. guilt
Erikson's psychosocial stage of initiative vs. guilt occurs in late childhood (3 to 6 years). PRE-SCHOOL AGE
PROLACTIN
Prolactin stimulates the secretion of milk.
The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance?
Answer: Walking three to five times a week for 30 minutes Rationale: One of the best exercises for an older adult is walking, with the goal of progressing to 30-minute sessions three to five times each week. Swimming and dancing are also beneficial.
Which of the following are components of Kohlberg's theory of moral development? Select all that apply.
- Moral development progresses in relation to cognitive development. - A person's ability to make moral judgments develops over a period of time. -The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. -In stage 2 (instrumental relativist orientation), the child conforms to rules to obtain rewards or to have favors returned.
Select the interventions that are appropriate for the care of an infant
- Provide swaddling. - Hang mobiles with black-and-white contrast designs. - Caress the infant while bathing or during diaper changes.
In planning care for older clients in a long-term care facility, the nurse recalls that which of the following is accurate regarding sexuality and the older client?
Answer: Although responses may be slower, sexual ability is present in later years of life.
A nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further instructions if the parent makes which statement?
Answer: "I should feed my child if she will not eat." Rationale: Toddlers have the skills required to feed themselves. Children who can feed themselves should not be fed or force fed. To increase nutritious intake, juice intake is limited to 6 ounces per day, and milk intake to 16 to 24 ounces per day. In addition, the nurse instructs the mother to limit nutritious snacks to two per day and to give them only at the toddler's request.
The nurse should plan which of the following to encourage autonomy in the client who is a resident in a long-term care facility?
Answer: Allowing him to choose his social activities Rationale: Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought.
A nurse is encouraging an older incontinent client's participation in recreational therapy. What nursing intervention would the nurse consider performing first?
Answer: Change the client's soiled disposable brief. Rationale: Basic physiological needs are a priority in administering nursing care.
A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse suggests which of the following to the mother?
Answer: "Allow the bottle if it contains water." Rationale: A toddler should not be allowed to fall asleep with a bottle because of the risk of dental caries. If the bottle is allowed in bed, it should contain only water.
A nurse is providing instructions to the mother of a 2-year-old child regarding dental care. Which statement by the mother indicates the need for further instructions?
Answer: "Proper dental care is not necessary for toddlers until their permanent teeth erupt."<--WRONG Rationale: The nurse should instruct the mother that proper dental care to a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries.
A parent of a 4-year-old child tells the nurse that she is concerned because the child has been masturbating. The appropriate response by the nurse is which of the following?
Answer: "This is a normal behavior at this age." Rationale: According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.
A nurse is caring for a 6-month-old infant. Which of the following should the nurse expect to note in this infant?
Answer: Babbles using single consonants Rationale: Using single-consonant babbling occurs between 6 and 8 months. Between 8 and 9 months the infant begins to understand and obey simple commands such as "wave bye-bye." Simple words as "Mama" and the use of gestures to communicate begin between 9 and 12 months.
During a well-child checkup for a 4-month-old the nurse teaches the mother how to introduce solid foods into her child's diet. The nurse determines that further teaching is required when the mother states:
Answer: "I will start giving home-prepared orange juice when my child is 3 months old." Rationale: Solids should be introduced over a period of time between the ages of 4 and 6 months. Failure to introduce solids by 6 months of age might prevent the child from accepting solids later. The pattern in which solids are introduced is not important as long as meats are introduced after cereals, fruits, and vegetables
The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse suggests which of the following to the mother?
Answer: "Inform the child of bedtime a few minutes before it is time for bed." Rationale: Most toddlers take an afternoon nap and until approximately age 2, some also require a morning nap. Toddlers often resist going to bed.
A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. According to Piaget's theory of cognitive development, this behavior is identified as:
Answer: Animism Rationale: Animism means that all inanimate objects are given living meaning. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development.
A 6-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which of the following play activities for the child?
Answer: A board game Rationale: The school-age child becomes organized, with more direction in play activities. School-age children's interests include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television.
When caring for a 3-year-old child, the nurse should provide which toy for this child?
Answer: A wagon Rationale: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys.
A nurse is working with an older client and family about discharge following hospitalization. When initiating discussions with the group, the nurse understands that older persons would prefer to live:
Answer: Independently, but close to their children Rationale: Most older people prefer to maintain their independence while having the resource of children or family nearby to help in times of need.
A nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which of the following statements?
Answer: "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." Rationale: client understands the purpose of the therapy and provides an incentive for the client to comply with the exercises
The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which of the following is the appropriate nursing response?
Answer: "It is best to ignore the behavior." Rationale: In the hospitalized preschooler, it is best to accept regression if it occurs, because it is most often caused by the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home
An older client confides to the visiting nurse that they are afraid they will fall while going to the bathroom at night. Which suggestion, if made by the nurse, indicates an understanding of the visual changes affecting the older client?
Answer: "Keep a red light on in the bathroom at night." Rationale: Because it takes longer to adapt to changes from dark to light and vice versa, older people are at greater risk for falls and injuries. Any place where there is a sudden change from dark to light or from light to dark can be dangerous.
A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old?
Answer: "The child may ignore the parents when they visit." Rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or by pretending to be more interested in play than in going home.
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention does the nurse suggest to alleviate the child's fears?
Answer: Encourage the child's parents to stay with the child. Rationale: Although the preschooler may already be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult.
A nurse is assessing the pain in a 3-year-old child after an appendectomy. Which pain scale should the nurse use?
Answer: FACES pain rating scale Rationale: There is a pain-rating tool identified with children as young as a neonate. Because the child in this question is 3 years old, the recommended pain scale is the FACES pain scale, which can be used with children as young as 3 years of age.
A nursing instructor asks a nursing student about the reason for the reduction of anesthetic medication dosage in the older person. The nursing student appropriately responds by stating:
Answer: "The increase of fatty tissue allows anesthetic agents, which have an affinity for fatty tissue, to concentrate in body fat." Rationale: An older person needs fewer anesthetic agents to produce anesthesia, and it takes longer for the older person to eliminate anesthetic agents. One reason for the reduction of dosage is that the percentage of fatty tissue increases as people age.
A nurse is collecting data from an older adult client. Which of the following indicates a potential complication associated with the skin of this client?
Answer: Crusting Rationale: he normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin indicates a potential complication.
A nurse is collecting data from a female client who is suspected of having mittelschmerz. Which of the following should the nurse expect to note?
Answer: Sharp pain located on the right side of the pelvis Rationale: The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days, and slight vaginal bleeding may accompany the discomfort.
A nurse assigned to care for an older adult client places an extra blanket in the client's room. The nurse understands that the older adult is less able to regulate hot and cold body changes because of alterations in the activity of the:
Answer: Sweat glands Rationale: Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation. The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels and by the activity of the sweat glands.
A nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is: "The child:
Answer: has the ability to think abstractly." Rationale: In the formal operations stage, the child has the abilities to think abstractly and solve problems.
The nurse should implement which activity to promote reminiscence among older clients?
Answer: Having storytelling hours Rationale: Clients who like to retell stories or to describe past events need to be provided with the opportunity to do so. This phenomenon is called life review or reminiscence.
An age-appropriate toy for a 1-month-old child is which of the following?
Answer: Nursery mobile Rationale: A nursery mobile is recommended for a 1-month-old child because it provides visual stimulation. If it is a musical nursery mobile, it also serves the purpose of providing auditory stimulation.
A 4-year-old child is reluctant to take deep breaths following abdominal surgery. The effective measure to encourage deep breathing is to:
Answer: Have the child pretend he is the big, bad wolf blowing the little pig's house down. Rationale: The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene.
According to Erik Erikson's psychosocial developmental theory, the nurse would anticipate a 5-year-old child to be in the stage of:
Answer: Initiative vs. guilt Rationale: A 5-year-old child would be expected to be experiencing Erikson's psychosocial stage of initiative versus guilt (late childhood, 3 to 6 years)
A nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, the nurse would instruct the parent to:
Answer: Allow the infant to signal a need. Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times, but rather must allow the infant to signal his or her needs. If an infant is not allowed to signal a need, he or she will not learn how to control the environment.
Which of the following describes Lawrence Kohlberg's first level of moral development?
Answer: Children determine the goodness or badness of an action in terms of the consequences. Rationale: Kohlberg's first level of moral development is the preconventional stage in which children determine the goodness or badness of an action in terms of the consequences.
A nurse in the pediatric unit is admitting a 2-year-old child. The nurse plans care, knowing that the child is in which stage of Erikson's psychosocial stages of development?
Answer: Autonomy vs. shame and doubt Rationale: A 2-year-old child, a toddler, is in the autonomy vs. shame and doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions and exerts himself or herself.
A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered?
Answer: Autonomy vs. shame and doubt Rationale: A widely accepted theory of personality development is that by Erik Erikson. Each of Erikson's eight stages has two components: the favorable and unfavorable aspects of the core conflict. No core conflict is ever totally mastered, and when individuals face new situations in life, they may revert to a previously mastered core conflict
A nursing instructor asks a nursing student to describe Montgomery's tubercles of the breast. Which response by the student indicates an understanding of this anatomical structure?
Answer: "These are sebaceous glands that are located in the areola."
The mother of a 4-year-old who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed and that it started when the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. The appropriate nursing response is which of the following?
Answer: "This is a normal occurrence following hospitalization." Rationale: Regression can occur in a preschooler and is most often caused by the stress of the hospitalization. It is best to accept the regression if it occurs. Parents may be overly concerned about regression and should be told that regression is normal following hospitalization.
According to Sigmund Freud's theory of personality development, the phallic stage is best described as which of the following? PHALLIC STAGE
Answer: (PHALLIC STAGE)----Children recognize differences between males and females. Rationale: Freud's phallic stage of development includes the recognition of differences between the sexes
A nurse prepares to take a blood pressure (BP) on a school-age child. To obtain an accurate measurement, the nurse places the blood pressure cuff so that it covers:
Answer: Two thirds the distance between the antecubital fossa and the shoulder Rationale: The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values and those that are too large will cause inaccurate low values. The cuff should cover two thirds the distance between the antecubital fossa and the shoulder.
A nursing student is preparing a conference on Freud's psychosocial stages of development, specifically the anal stage. Which of the following appropriately relates to this stage?
Answer: Beginning of toilet training Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces
A nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a nursing student to identify the structure in which fertilization of an ovum takes place. The student answers correctly by identifying which location?
Answer: Fallopian tube Rationale: The fallopian tubes are a pathway for the ovum between the ovary and the uterus. Fertilization occurs in the fallopian tube.
A nurse prepares to discharge a client who is experiencing family-related stress. Which goal does the nurse include to help the client achieve her primary developmental task?
Answer: Help the client to resume her familial role. Rationale: The primary developmental task of middle adulthood is to realize generativity and to help guide children or the next generation through social situations in a productive manner. Thus the nurse helps the client reclaim her role in the family as mentor and facilitator to avert stagnation in society
A nurse is assessing a 36-month-old child during a wellness visit to the pediatrician. The child weighs 43 pounds and is 41 inches tall. After plotting the measurements on the standardized growth charts for a 36-month-old, what should the nurse do next?
Answer: Assess the parents' body shape and stature. Rationale: A strong correlation exists between parent and child with regard to traits such as height, weight, and rate of growth. Most physical characteristics, including shape and form of features, body build, and physical peculiarities are inherited and influence the way in which children grow and interact with their environment.
An older client is taking multiple medications for a variety of health problems. The nurse would monitor the results of which of the following most important laboratory tests when evaluating adverse effects of medication therapy in the older adult?
Answer: Creatinine Rationale: Creatinine should be most closely monitored because it relates to kidney function. Because many medications are excreted by the kidneys, that makes this the laboratory test of choice for ongoing monitoring.
During a well-child visit a mother states she is frustrated with her 2-year-old child. Whenever she asks him if he wants something to eat, he says, "No," but then he starts to cry when she does not give him the food. Which of the following statements by the nurse would indicate an understanding of psychosocial concepts related to growth and development of the toddler?
Answer: "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." Rationale: According to Erikson, toddlers are acquiring a sense of autonomy while overcoming a sense of shame and doubt. They are attempting to relinquish their dependence and asserting independence, which will be present as negativism in their quest for independence. The word "no" is a very strong part of their vocabulary.
A nurse is providing instructions to a 16-year-old male adolescent regarding dietary patterns. The nurse instructs the adolescent that the recommended amount of daily calories is approximately:
Answer: 2200 Rationale: The recommended amount of daily calories for a male adolescent between the ages of 15 and 18 years is 2200.
A 16-year-old adolescent is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the following interventions is most appropriate to facilitate normal growth and development?
Answer: Allow the child to participate in activities with other individuals in the same age group when the condition permits. Rationale: Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety.
A client with sickle cell anemia has vaso-occlusive pain. After noting that the client is of preschool age, the nurse plans to use which of the following methods to determine the adequacy of pain control methods?
Answer: Ask the client to point to faces (smiling to very sad) that best describe the pain. Rationale: A client of preschool age has the cognitive ability to recognize happy and sad faces and to correlate them with the level of pain experienced. Using descriptive words to communicate varying intensities of pain may be too complicated for some preschoolers
Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which of the following actions should the nurse take?
Answer: Document the findings. Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age.
According to Erik Erikson's psychosocial developmental theory, the nurse would anticipate an adolescent to be in the stage of: ADOLESCENT STAGE
Answer: Identity vs. role confusion Rationale: An adolescent (1 to 20 years) would be expected to be experiencing Erikson's psychosocial stage of identity vs. role confusion
A nurse is providing information to nursing assistants regarding caring for the older adult. The nurse tells the nursing assistants that which of the following situations portrays ageism?
Answer: Advising older adults to forgo aggressive treatment Rationale: Ageism is a form of prejudice, in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different from "me" and will remain different from "me."
A nurse has gathered data about each of the following items about an older client. The nurse understands that which of the following is not a reliable indicator of fluid imbalance for a client in this age group?
Answer: Thirst Rationale: Thirst in the older adult is subjective and is not always consistent with fluid balance. The appearance of oral mucosa, skin turgor, and the differences between intake and output are more reliable measures of fluid balance in the older adult.
A nursing instructor asks a nursing student about Kohlberg's theory of moral development. The instructor determines that the student needs to further research this theory if the student states that a component of the theory includes which of the following?
Answer: Individuals move through all six stages in a sequential fashion. Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal mortality.
A client who has been seen in the clinic has been diagnosed with endometriosis and asks the nurse to describe this condition. The nurse bases the response on which of the following?
Answer: It is the presence of tissue outside the uterus that resembles the endometrium. Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium.
A nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the anatomical structure that supports and protects the internal reproductive organs. The student correctly responds by identifying which structure?
Answer: Pelvis Rationale: The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs.
A nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse should recall that adolescents:
Answer: Like to stay up late but rarely have insomnia Rationale: The signs of depression include crying spells, insomnia, eating disorders, social isolation and withdrawal, serious acting-out behavior, feelings of hopelessness, unexplained physical symptoms, loss of interest in appearance, and giving away things or possessions.
A pediatric nurse is caring for a hospitalized toddler. The nurse determines that the appropriate play activity for the toddler is which of the following?
Answer: Playing with a push-pull toy Rationale: The toddler has increased use of motor skills and enjoys manipulating small objects such as toy people, cars, and animals.
The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse provide to the parent?
Answer: Set limits on the child's behavior. Rationale: According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes
The parents of a 2-year-old arrive at the hospital to visit the child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which of the following?
Answer: That the child is exhibiting a normal pattern rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home.
When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.
- Decline in visual acuity - Increased susceptibility to urinary tract infections - Increased incidence of awakening after sleep onset
A nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which of the following?
Answer: Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization Rationale: A 10-month-old is in the trust vs. mistrust stage of psychosocial development, according to Erikson. The infant is developing a sense of self, and the nurse should most appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and to provide sensory stimulation.
A nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which of the following, if noted during the assessment, would present the greatest hazard to the children?
Answer: Toys with small loose parts in the playroom Rationale: Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouths, which could lead to aspiration and choking.
During a routine well-child checkup for a 2-year-old, the nurse plans to teach the mother proper nutrition and weight gain expectations for her child. The nurse reviews the chart and finds that the toddler's birth weight was 7 pounds 15 ounces. The nurse expects that the child should weigh approximately how much at this time?
Answer: 31 pounds 12 ounces Rationale: By the age of 2½ years, the toddler should have quadrupled his or her birth weight. The child doubles the birth weight by age 5 to 6 months and triples the birth weight by 1 year of age.
A nurse is collecting data regarding the motor developmental of a 24-month-old child. Based on the age of the child, the nurse expects to note which highest level of developmental milestone?
Answer: The child uses a doorknob to open a door. Rationale: A 24-month-old would be able to use a doorknob to open a door. At age 15 months, the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently.
The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. The appropriate response by the nurse is which of the following?
Answer: "You may give the child a bottle if necessary, but if you do, it should contain water." Rationale: A child should never be allowed to fall asleep with a bottle because of the risk of bottle-mouth caries.
