Exam 1: Saunders

The nurse is performing an assessment on an older adult client.Which assessment data would indicate a potential complication associated with the skin? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin

1 The 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 would indicate a potential complication.

The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4. In the preschooler, play is simple and imaginative, and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or a sports video ismost appropriate for the adolescent. Large picture books are most appropriate for the infant.

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

Anatomical changes to the eye affect the individual's visual ability, leading to potential problemswith activities of daily living. Light adaptation and visual fields are reduced. Although lung function may decrease, the respiratory rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memorymay decline with age, but long-term memory usually is maintained. Change in sleep patterns is a consistent, age-related change. Older persons experience an increased incidence of awakening after sleep onset.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse? 1. A man who has moderate hypertension 2. A man who has newly diagnosed cataracts 3. Awoman who has advanced Parkinson's disease 4. A woman who has early diagnosed Lyme disease

3 Elder abuse includes physical, sexual, or psychological abuse; misuse of property; and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least 1 physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim 3 times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime."

3 Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. Smoking and alcohol should be avoided. Reading is also a helpful measure and is relaxing.

The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. What should the nurse tell the UAP about older clients with hearing loss? 1. They are often distracted. 2. They have middle ear changes. 3. They respond to low-pitched tones. 4. They develop moist cerumen production

3 Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearingability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options1,2,and 4 arenot accurate characteristics related to aging.

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take? 1. Report the observation to the health care provider. 2. Move the objects in the child's direct field of vision. 3. Teach the child how to visually scan the environment. 4. Provide additional lighting for the child during play activities.

1. According to Jean Piaget's theory of cognitive devel- opment, it is normal for the infant or toddler not to recognize that objects continue to be in existence, even if out of the visual field; however, this is abnormal for the 6-year-old. If a 6-year- old child does not recognize that objects still exist even when outside the visual field, the child is not progressing normally through the developmental stages. The nurse should report this finding to the health care provider. Options 2, 3, and 4 delay necessary follow-up and treatment.

A4-year-old child diagnosed with leukemia is hos- pitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1. Although the preschooler already may be spending some time away from parents at a day care center or preschool, illnessaddsa stressor thatmakes separation moredifficult.The child mayask repeatedlywhen parentswill be comingfor a visit ormay constantlywant to call the parents.Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who maybe immunocompromised and at risk for infection.

A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess our children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."

1. Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners on the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended or within the child's reach, and the toddler should always be supervised. The statements in options 2, 3, and 4 do not indicate an understanding of the principles of safety.

Themother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A farm set 4. A jack set with marbles

1. Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need CHAPTER 22 Developmental Stages 279 supervision at all times. Push-pull toys, large balls, large crayons, large trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow.

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The stu- dent explains to the group that which characteristic relates to this stage of development? 1. This stage is associated with toilet training. 2. This stage is characterized by the gratification of self. 3. This stage is characterized by a tapering off of conscious biological and sexual urges. 4. This stage is associated with pleasurable and conflicting feelings about the genital organs.

1. n general, toilet training occurs during the anal stage. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option 2 relates to the oral stage. Option 3 relates to the latency period. Option 4 relates to the phallic stage.

A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply. 1. Set limits on the child's behavior. 2. Ignore the child when this behavior occurs. 3. Allow the behavior, because this is normal at this age period. 4. Provide a simple explanation of why the behavior is unacceptable. 5. Punish the child every time the child says "no" to change the behavior.

1. 4. According to Erikson, the child focuses on gaining some basic control over self and the environment and indepen- dence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents'wishes. Say- ing things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options 2 and 3 do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern.

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at nap time. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1. 4. 5. Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright shiny object in midline within 20 to 25 cm of the infant's face and hanging mobiles with contrasting colors, such as black and white, provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containingmilk, juice, soda pop, sweetened water, or another sweet liquid because of the risk of nursing (bottle-mouth) caries.

The maternity nurse is providing instructions to a new mother regarding the psychosocial develop- ment of the newborn infant. Using Erikson's psy- chosocial development theory, the nurse instructs the mother to take which measure? 1. Allow the newborn infant to signal a need. 2. Anticipate all needs of the newborn infant. 3. Attend to the newborn infant immediately when crying. 4. Avoid the newborn infant during the first 10 minutes of crying.

1. According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? 1. The child has the ability to think abstractly. 2. The child begins to understand the environ- ment. 3term-23. The child is able to classify, order, and sort facts. 4. The child learns to think in terms of past, pre- sent, and future.

1. In the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete oper- ational stage. Option 4 identifies the preoperational stage.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? 1. Check for medication interactions. 2. Determine whether there are medication duplications. 3. Call the prescribing health care provider (HCP) and report polypharmacy. 4. Determine whether a familymember supervises medication administration.

2 Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined, because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? 1. Decreased absorption of digoxin 2. Increased risk for digoxin toxicity 3. Decreased therapeutic effect of digoxin 4. Increased risk for side effects related to digoxin

2 The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate. This age-related change is not specifically associated with decreased absorption, decreased therapeutic effect, or increased risk for side effects. Toxicity, or toxic effects, occurs as a result of excessive accumulation of the medication in the body.

The home care nurse is visiting an older client whose spouse died 6 months ago.Which behaviors by the client indicates effective coping? Select all th at apply. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

2 3 4 5 Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? 1. Allow the bottle if it contains juice. 2. Allow the bottle if it contains water. 3. Do not allow the child to have the bottle. 4. Allow the bottle during naps but not at bedtime.

2. A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or any other sweet liquid because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water.

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into a cup 4. Uses a knife for cutting food

2. By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids. 2. Document the finding. 3. Notify the health care provider (HCP). 4. Elevate the head of the bed to 90 degrees.

2. The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the HCP, or elevate the head of the bed to 90 degrees.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the health care provider. 4. Reassess the respiratory rate in 15 minutes.

2. The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/minute. The normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the the- ories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply. 1.Individuals move through all 6 stages in a sequential fashion. 2. Moral development progresses in relation- ship to cognitive development. 3. A person's ability to make moral judgments develops over a period of time. 4. The theory provides a framework for under- standing how individuals determine a moral code to guide their behavior. 5. In stage 1 (punishment-obedience orienta- tion), children are expected to reason as mature members of society.

2. 3. 4. 6. Kohlberg's theory states that individuals move through stages of development in a sequential fashion but that not everyone reaches stages 5 and 6 in his or her development of personal morality. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It states that moral development pro- gresses in relationship to cognitive development and that a per- son's ability to make moral judgments develops over a period of time. In stage 1, ages 2 to 3 years (punishment-obedience orientation), children cannot reason as mature members of society. In stage 2, ages 4 to 7 years (instrumental-relativist ori- entation), the child conforms to rules to obtain rewards or have favors returned.

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial devel- opment theory, the nurse should make which response? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "At this age, the child is developing his own personality." 4. "You need to provide more praise to the child to stop this behavior."

3. According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents. Therefore options 1, 2, and 4 are incorrect responses.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know they will not be abandoned by the nurse.

3. 5. 6. Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? 1. Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." 2. Suggest to the client and daughter-in-law that they consider a nursing home for the client. 3. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. 4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

4 Assisting clients and families to become aware of available community support systems is a role and responsibility of the nurse. Observing that the client has begun to be confined to his room makes it necessary for the nurse to intervene legally and ethically, so option 3 is not appropriate and is passive in terms of advocacy. Option 2 suggests committing the client to a nursing home and is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of the nursing care required. Option 1 is incorrect and judgmental.

The nurse is caring for an older client in a long-term care facility.Which action contributes to encouraging autonomy in the client? 1. Planning meals 2. Decorating the room 3. Scheduling haircut appointments 4. Allowing the client to choose social activities

4 Autonomy is the personal freedom to direct one's own life as longas it does not impinge on the rights ofothers.An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. The correct option is the only one that allows the client to be a decision maker.

A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums. 3. Avoid letting the child nap during the day. 4. Inform the child of bedtime a few minutes before it is time for bed.

4. Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent before-bedtime routine and enforcing consistent limits regarding the child's bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics.

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tellthe parent that which factor motivates good & bad actions for the child at the preconventional level? 1. Peer pressure 2. Social pressure 3. Parent's behavior 4. Punishment & reward

4. In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedi- ent and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated factors for this stage of moral development.

A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read. 2. Encourage the parents to room in with the client. 3. Allow the family to bring in the client's favorite computer games. 4. Allow the client to interact with others in h is or her (Adolescen t) same age group.

Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the client from the peer group.

Which car safety device should be used for a child who is 8 years old and 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

All children whose weight or height is above the forward-facing limit for their car safety seat should use a beltpositioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infantonly seat or a convertible seat until theyweigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.