HEALTH PROMOTION AND MAINTENANCE 3/11/23
A parent brings an 8-month-old to the pediatrician's office. When the nurse approaches to measure the child's vital signs, the child clings to the parent tightly and starts to cry. The parent says, "The baby used to smile at everyone. I don't know why the baby is acting this way." The nurse begins teaching the parent about growth and development by stating: "Your baby's behavior indicates stranger anxiety, which is common at his age." "Children at this age begin to fear pain." "Your baby's having a temper tantrum, which is common at this age." "Children who behave that way are developing shy personalities."
"Your baby's behavior indicates stranger anxiety, which is common at his age." Explanation: Stranger anxiety, common in infants aged 6 to 8 months, may cause the child to cry, cling to the caregiver, and turn away from strangers. Typically, it occurs when the child starts to differentiate familiar and unfamiliar people. The child's behavior doesn't necessarily indicate shyness. According to Piaget, fear of pain characterizes the operational stage of development in school-aged children, not infants. Temper tantrums are typical in toddlers who are trying to assert their independence. During a temper tantrum, children may kick, scream, hold their breath, or throw themselves onto the floor rather than cling to a parent.
When discussing the onset of adolescence with parents, the nurse explains that it occurs at what time? 1 to 2 years earlier in girls than in boys Same age for both boys and girls 1 to 2 years earlier in boys than in girls 3 to 4 years later in boys than in girls
1 to 2 years earlier in girls than in boys Explanation: Girls experience the onset of adolescence about 1 to 2 years earlier than boys. The reason for this is not understood.
The father of a neonate observes that the neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. How should the nurse should interpret this finding?
Babinski's sign Explanation: A positive Babinski's sign involves dorsiflexion of the big toe and fanning of the other toes. Although normal in infants, this response is abnormal after about age 1 year or when walking begins. The stepping reflex occurs when an infant is held as though weight bearing with the feet on a surface and the infant steps along, raising one foot at a time. A plantar grasp reflex is characterized by flexion of the toes when a finger is placed against the base of the toes. A normal Galant reflex is initiated by stroking an infant's back alongside the spine. The hips should move toward the stimulated side.
The nurse lifted up a neonate from the bassinet. The neonate became startled, extended the arms with hands open and started crying. What intervention would be most appropriate for the nurse? Give the neonate a pacifier. Do a complete neurological examination. Document the finding as a normal response. Contact the health care provider.
Document the finding as a normal response. Explanation: The Moro or startle reflex is present in all neonates up until 3 to 4 months of age. It has three components: spreading out the arms (abduction), pulling the arms in (adduction), and crying. With the arms outstretched, the palms of the hands are up and open with the thumbs being flexed. This reflex occurs as a response to a sudden loss of support. It is a normal response, so the nurse would document as such. There is no need to notify the health care provider or do a neurological exam. A pacifier will not prevent the Moro reflex but it may help soothe the neonate after being startled. Even though it is a caring intervention it is not the most important. The most important is to know if the reflex is present or absent.
After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal? Encourage self-care skills in the child. Achieve age-appropriate social skills. Teach the child something new each day. Encourage more lenient behavior limits for the child.
Encourage self-care skills in the child. Explanation: The goal in working with children with intellectual disabilities is to train them to be as independent as possible, focusing on developmental skills. The child may not be capable of learning something new every day but he or she does need to repeat what has been taught previously. Rather than encouraging more lenient behavior limits, the parents need to be strict and consistent when setting limits for the child. Most children with Down syndrome are unable to achieve age-appropriate social skills due to their disability. Rather, they are taught socially appropriate behaviors.
When interviewing an adolescent client, in which of the following instances will the nurse be most successful in obtaining relevant health information? Asking the fewest possible questions so that the client does not lose interest Ensuring that the parents remain in the room Checking social media sites for the latest slang Maintaining objectivity by avoiding assumptions, judgments, and lectures
Maintaining objectivity by avoiding assumptions, judgments, and lectures Explanation: Maintaining objectivity will ensure the best communication with the adolescent client. Including the parents is not conducive to the teen client being open and honest with the nurse. The nurse does not need to know the current slang to communicate. The art of being succinct is not necessarily the best strategy.
Parents ask the nurse for advice about handling their 2-year-old's negativism. What is the best recommendation? Set realistic limits for the child, and then be sure to stick to them. Ignore this behavior because it is a stage the child is going through. Encourage the grandmother to visit frequently to relieve them. Punish the child for misbehaving or violating set, strict limits.
Set realistic limits for the child, and then be sure to stick to them. Explanation: A characteristic of 2-year-olds is negativism, a response to their developing autonomy. Setting realistic limits is important so that the toddler learns what behavior is and is not acceptable. Ignoring the behavior may lead the child to believe that there are no limits. As a result, the child does not learn appropriate behavior. Having the grandmother visit will give the parents a break, but setting limits is more important to the child's development. Limits need to be realistic to ensure that the child learns appropriate behavior. Limits that are too strict are inappropriate, interfering with learning appropriate behavior.
The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. Then nurse informs the parents that the development of a child's spirituality is best accomplished by: Teaching through religious-based schools. Teaching the child about religion. Teaching the child about God. Teaching through parental behaviors.
Teaching through parental behaviors. Explanation: A child's parents play a key role in the development of the child's spirituality. What is important is not so much what parents teach a child about God and religion, but rather what the child learns about God, life, and self from the parent's behavior.
The nurse is caring for an infant in the emergency room who has symptoms of irritability and a high fever. When assessing for increased intracranial pressure using the anterior fontanel, identify the area where the nurse would palpate.
The anterior fontanel is formed by the junction of the sagittal, frontal, and coronal sutures. It is shaped like a diamond and normally measures 4 to 5 cm at its widest point. A widened, bulging fontanel is a sign of increased intracranial pressure.
A 7-year-old child has taken a game from the hospital playroom that was supposed to remain in that area. The nurse should discuss the problem with the mother and make which recommendation? The child needs to apologize and return the game to the playroom. That this is an indication that something is seriously wrong with the child. The child needs to receive serious punishment for the stealing. The mother needs to have a long talk with the child to explain why the behavior was wrong.
The child needs to apologize and return the game to the playroom. Explanation: In most situations, children ages 5 to 8 have not yet developed respect for others' property. They may take something, such as money or a game, because they are attracted to it. Serious punishment is inappropriate. A long talk is not warranted in this situation because the child is unable to maintain attention for a long period. This behavior usually is not an indication of a serious problem in the child.
When assessing an infant with an undescended testis, the nurse should be alert for which symptom? a history of frequent emesis poor weight gain abnormal lower extremity reflexes a bulging in the inguinal area
a bulging in the inguinal area Explanation: When an anomaly is found in one system, such as the genitourinary system, that system requires a more focused assessment to reveal other conditions that also may be occurring. A bulging in the inguinal area may suggest an inguinal hernia. Also, hydrocele or an upper urinary tract anomaly may occur on the same side as the undescended testis. A neuromuscular problem, not a genitourinary problem such as undescended testes, would most likely be the cause of abnormal lower extremity reflexes. A history of frequent emesis may be caused by pyloric stenosis or viral gastroenteritis. Poor weight gain might suggest a metabolic or a feeding problem.
The nurse needs to assess an infant's height to determine if the infant is meeting appropriate growth and development parameters. To obtain the most accurate measurement of an infant's height (length), the nurse measures the:
recumbent height with the infant supine. Explanation: For the most accurate measurement, the nurse should place the infant in a supine position and then measure recumbent height. Measuring recumbent height with the infant lying on the side would yield an inaccurate result. Measuring recumbent height with the infant prone would yield an inaccurately long result because it includes the length of the foot. Measuring standing height with the infant held upright would also yield an inaccurate result, at least until the child no longer needs assistance to stand up straight.
When performing a physical examination on a neonate, the nurse notes low-set ears. What action should the nurse perform next? Assess the neonate to determine if other apparent abnormalities are present. Call the pediatrician for an immediate evaluation of the infant. Order an ultrasound of the head to determine if the brain is normal. Note the findings in the medical record.
Assess the neonate to determine if other apparent abnormalities are present. Explanation: Although low-set ears are an abnormal finding, the presence of this abnormality by itself isn't cause for immediate concern. The nurse should continue to assess the neonate to determine if other abnormalities are present. It's appropriate to note the abnormality in the medical record; however, it's even more important to continue the assessment. It's outside the scope of nursing practice to order a diagnostic test, such as an ultrasound, and there's no indication for this test.
A nurse is assessing a postoperative client. Which information would the nurse document as subjective data? Client's incisional dressing shows a small amount of sanguineous drainage. Client reports incisional pain as a level 3 on a pain scale of 1-10. Client's bowel sounds are hypoactive in four quadrants. Client's pulse measures 84 beats/minute.
Client reports incisional pain as a level 3 on a pain scale of 1-10. Explanation: Subjective data come directly from the client and are usually recorded as direct quotations that reflect the client's opinions or feelings about a situation (what the client says). The client's report of pain as level 3 on a scale from 1-10 is the client's description of the pain. Vital signs, bowel sounds, and incisional drainage are considered objective data (what the nurse observes).
A nurse is performing a cardiac assessment. Identify where the nurse places the stethoscope to best auscultate the pulmonic valve.
The pulmonic area is best heard at the second intercostal space, just left of the sternum.
A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? Up to 10 Up to 20 Up to 15 Up to 32
Up to 20 Explanation: A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13.
The nurse is invited to attend a meeting with several parents who express frustration with the amount of time their adolescents spend in front of the mirror and the length of time it takes them to get dressed. What does the nurse explain that this behavior indicates? a method of procrastination a way of testing the parents' limit-setting an abnormal narcissism a result of developing self-concept
a result of developing self-concept Explanation: An adolescent's body is undergoing rapid changes. Adolescence is a time of integrating these rapidly occurring physical changes into the self-concept to achieve the developmental task of a positive self-identity. Thus, most adolescents spend much time worrying about their personal appearance. This behavior is not abnormal narcissism, a method of procrastination, or a way of testing the parents' limits.
The nurse is providing health screening for adolescent girls. Which of the following adolescent girls does the nurse identify as highest risk for an unplanned pregnancy? Select all that apply. an adolescent girl with low self-esteem an adolescent girl living in poverty an adolescent girl dating an older boy an adolescent girl with low educational achievement an adolescent girl who believes in abstinence
an adolescent girl living in poverty an adolescent girl with low self-esteem an adolescent girl with low educational achievement an adolescent girl dating an older boy Explanation: Young women may try to use a pregnancy to escape a poor living situation. Those with low education and literacy levels may not possess the knowledge or information needed to protect themselves from unwanted pregnancies. A young woman with low self-esteem may be pressured into a sexual relationship, especially when involved with an older boy, resulting in an unwanted pregnancy.
When the nurse is teaching a group of parents about common childhood problems, a parent asks, "Why are children more likely to develop ear infections than adults are?" The nurse bases the response to this question on the understanding that the key anatomic difference between adults and children is due to which structure? eustachian tubes ear canals tympanic membranes nasopharynx
eustachian tubes Explanation: In infants and young children, the eustachian tubes are short and lie in a relatively horizontal position. This anatomic position favors the development of otitis media because it is easy for materials from the nasopharynx to enter the tubes.Although bacteria may be present in the nasopharynx, this does not affect middle ear function.The size of the ear canal has no impact on the increased number of ear infections in children. An intact tympanic membrane prevents bacteria from entering the middle ear from the external ear canal. The tympanic membrane changes appearance with an ear infection, but its structure does not predispose infants and young children to ear infection.
The nurse is working with a client with low proficiency in the dominant language. The client's spouse is fluent in both the client's language and the area's dominant language. What is the best action by the nurse when providing discharge education to the client and spouse? Obtain the services of a medical interpreter. Speak slowly and face the client. Have the spouse act as the interpreter. Direct the teaching to the client's spouse.
Obtain the services of a medical interpreter. Explanation: The best action by the nurse is to obtain the services of a medical interpreter. Speaking slowly and facing the client will not ensure that the client understands the information presented. Asking the spouse to act as an interpreter is not appropriate. Directing teaching to the spouse excludes the client and is, therefore, not appropriate.
An older adult is taking eight medications to manage hypertension, diabetes, and arthritis and reports having nausea, diarrhea, tremors, and unusual thoughts. When investigating the cause of these symptoms, the nurse should consider which reason for underestimating adverse drug reactions in older adults? Adverse reactions rarely have an atypical presentation. Physical or psychological symptoms are attributed to the effects of aging. Cognitive impairment is an expected finding in the older adult client. Excess sedation is difficult to assess in the older adult.
Physical or psychological symptoms are attributed to the effects of aging. Explanation: The elderly client commonly has vague or atypical responses to medications and diseases that are erroneously attributed to aging. A new cognitive change needs to be investigated and is not an expected change with aging. Changes in a client's behavior should be investigated to see whether there is a relation to excessive sedation. The nurse can interview the family members to obtain information.
When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly? pulse respirations temperature blood pressure
blood pressure Explanation: The incidence of hypertension is three to six times greater in clients using hormonal contraceptives than in women who don't use these drugs. Age and duration of the drug's use increase this incidence. Hormonal contraceptives don't directly affect pulse, respirations, or temperature.
According to Erikson's theory of development, chronic illness can interfere with which stage of development in an 11-year-old child? industry versus inferiority intimacy versus isolation trust versus mistrust identity versus role confusion
industry versus inferiority Explanation: According to Erikson, an 11-year-old child is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old child because the child may not be able to accomplish tasks, which prevents the child from achieving a sense of industry. Intimacy is the developmental task of a young adult. Trust is the developmental task to be achieved during infancy. Identity is the developmental task of adolescence.
When developing a care plan for a hospitalized client, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? adolescence preschool age school age infancy
preschool age Explanation: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.
A nurse is teaching the parents of a 7-year-old child about the use of protective restraints in the car to help avoid spinal cord injuries in car accidents. The child weighs 20 kg (44 lb). Which of the following information should the nurse emphasize in the teaching? using a lap seatbelt using a booster seat using a rear-facing car seat using a lap and shoulder belt
using a booster seat Explanation: A child must weigh 18 kg (40 lb) to move from a front-facing seat to a booster seat. The booster seat is used until the child outgrows it and the lap and shoulder belt fit correctly.
A nurse correctly identifies which items as belonging to the dorsal cavity? reproductive organs mediastinum vertebral canal mouth
vertebral canal Explanation: The dorsal cavity consists of the cranial (skull) and vertebral canal (spinal cavity). The mediastinum and reproductive organs are located in the ventral cavity. The mouth is located in the oral cavity.
A child, age 4, is brought to the clinic for a routine examination. When observing the tympanic membrane, the nurse identifies which color as normal? yellowish white deep red light pink pinkish gray
pinkish gray Explanation: The tympanic membrane normally appears pinkish gray, shiny, and translucent. A light pink, deep red, or yellowish white tympanic membrane is abnormal.
Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine? the reasons they choose to use alcohol the type of alcohol they usually drink what they know about the legal implications of drinking when and with whom they use alcohol
the reasons they choose to use alcohol Explanation: Information about why adolescents choose to use alcohol or other drugs can be used to determine whether they are becoming responsible users or problem users. The senior students likely know the legal implications of drinking, and the nurse will establish a more effective relationship with the students by understanding motivations for use. The type of alcohol and when and with whom they are using it are not the first data to obtain when assessing the situation.
When examining a client who has abdominal pain, a nurse should assess the symptomatic quadrant first. the symptomatic quadrant either second or third. any quadrant first. the symptomatic quadrant last.
the symptomatic quadrant last. Explanation: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.
A mother comes to the clinic with her 5-year-old child who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're midway between the tonsillar pillar and the uvula. touching the uvula. barely visible outside the tonsillar pillar. touching each other.
touching the uvula. Explanation: Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are rated 4+.
The parent of a 6-month-old reports starting 2% milk. What should the nurse ask the parent first? "Do you think your baby will be fine with this milk?" "Is it possible for you to switch your baby to whole milk?" "Can you tell me more about the reason you switched your baby to 2% milk?" "You cannot switch to 2% milk right now. Did your pediatrician tell you to do this?"
"Can you tell me more about the reason you switched your baby to 2% milk?" Explanation: The American Academy of Pediatrics and Canadian Pediatric Society recommend that infants remain on iron-fortified formula or breast milk until 1 year of age. The nurse needs to first assess if the parent switched the baby prematurely to due to lack of information or lack of resources. Then appropriate teaching or referrals may be determined. At 1 year of age, the infant may be switched to whole milk, which has a higher fat content than 2%. The higher fat content is needed for brain growth. Demanding clients change behaviors without addressing the cause is unlikely to produce desired results.
A 10-month-old looks for objects that have been removed from his view. How does the nurse explain the finding to the parents? The child understands objects are there even though the child cannot see them. The child is showing typical neuromuscular development. The child is now able to transfer objects from hand to hand. The child's curiosity has increased.
The child understands objects are there even though the child cannot see them. Explanation: Understanding object permanence means that the child is aware of the existence of objects that are covered or displaced. Neuromuscular development, curiosity, and the ability to transfer objects are not associated with the principle of object permanence. Although, at 10 months, neuromuscular development is sufficient to grasp objects and a child's curiosity has increased, neither are related to the thought process involved in object permanence.
A caregiver brings a 19-month-old client to the clinic for a regular checkup. When palpating the client's fontanels, what should the nurse expect to find? closed anterior and posterior fontanels open anterior fontanel and closed posterior fontanel closed anterior fontanel and open posterior fontanel open anterior and posterior fontanels
closed anterior and posterior fontanels Explanation: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.
The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to which problem? vitamin C deficiency folate deficiency iron deficiency biotin deficiency
iron deficiency Explanation: Excessive milk consumption can lead to the displacement of iron-rich foods in the diet. This can result in iron deficiency anemia. Drinking excess milk will not cause vitamin C, biotin, or folate deficiencies.
When assessing a 2-year-old child at the clinic for a routine checkup, which skill should the nurse expect the child to be able to perform? using blunt scissors riding a tricycle tying shoelaces kicking a ball forward
kicking a ball forward Explanation: A 2-year-old child usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt scissors is characteristic of a 3-year-old child.
The nurse assesses a teenage girl's musculoskeletal system (see figure). What finding should the nurse document? scoliosis lordosis normal posture kyphosis
lordosis Explanation: This girl has an exaggeration of the lumbar spine, swayback, or lordosis. Kyphosis is an increased convexity or roundness of the curve of the thoracic spine. Scoliosis is a lateral curvature of the spine.
The nurse is providing nutrition counseling for an obese adolescent. What is the most effective way for the nurse to obtain a nutrition history from this client? Telephone her mother and ask her what she ate yesterday. Ask her what she knows about good nutrition. Ask her what she ate yesterday if it was a typical day. Tell her to list what she plans to eat for the next 24 hours.
Ask her what she ate yesterday if it was a typical day. Explanation: A 24-hour recall history is the best method to obtain a dietary history from an adolescent. Open-ended questions tend not to provide sufficient details for a nutrition history. Asking what the client plans to eat in the future gives the client an opportunity to report the "right" answer. The nurse obtains the information directly from the client; asking the mother has the potential to undermine trust.
A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method? Place a tongue blade lightly on the posterior aspect of the pharynx. Place a tongue blade on the uvula. Place a tongue blade on the front of the tongue and ask the client to say "ah." Place a tongue blade on the middle of the tongue and ask the client to cough.
Place a tongue blade lightly on the posterior aspect of the pharynx. Explanation: To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the pharynx with a tongue blade, which should elicit gagging. Having the client say "ah" allows the nurse to evaluate cranial nerves IX and X. However, the nurse needn't use a tongue blade to hold down the tongue; the client need only stick out their tongue. Placing a tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client.
When auscultating a client's chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound? opening of the mitral and tricuspid valves opening of the aortic and pulmonic valves closing of the mitral and tricuspid valves closing of the aortic and pulmonic valves
closing of the aortic and pulmonic valves Explanation: The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.
During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data? subjective secondary source medical objective
objective Explanation: Physical examination techniques such as auscultation provide objective data, which reflect findings without interpretation. The client and client's family report subjective data to the nurse. The family and members of the healthcare team provide secondary source information. The nurse obtains medical data from the physician and medical record.
A nurse is auscultating for heart sounds in a client. The nurse notes a grade 1 heart murmur. Which characteristic best describes a grade 1 heart murmur? equal in loudness to the heart sounds softer than the heart sounds associated with a precordial thrill can be heard without a stethoscope
softer than the heart sounds Explanation: A grade 1 heart murmur is commonly difficult to hear and softer than heart sounds. A grade 2 murmur is usually equal in sound to the heart sounds. A grade 4 murmur is associated with a precordial thrill (a palpable manifestation associated with a loud murmur). A grade 6 murmur can be heard without a stethoscope.
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess? appearance of age-related wrinkles changes from the normal expected findings skin turgor similarities from one side to the other
changes from the normal expected findings Explanation: Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system
When a client is examining her own breast, the nurse should instruct the client that which finding is normal? pronounced unilateral venous pattern long-term, bilateral nipple inversion peau d'orange breast tissue breast tissue that is darker than the areolae
long-term, bilateral nipple inversion Explanation: It is a normal variation for women to have long-term, bilateral nipple inversion. A woman who has a unilateral nipple inversion that is a new change is at risk for a tumor; the weight of the tumor causes pulling on the nipple. A pronounced unilateral venous pattern, peau d'orange breast tissue, and breast tissue darker than the areolae are definite warning signals for breast cancer that must be reported to the health care provider (HCP) immediately.
The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. What does the nurse determine is the family's risk of having another child with sickle cell anemia? one chance in two for each pregnancy one chance in three for each pregnancy one chance in five for each pregnancy one chance in four for each pregnancy
one chance in four for each pregnancy Explanation: Sickle cell disease is an autosomal recessive Mendelian disorder. Therefore, if both parents have the trait, there is a one-in-four chance that any child (each pregnancy) will have the disease and a one-in-two chance that a child (each pregnancy) will have the trait.
The parent of a 12-month-old child expresses concern about the effects of the child's frequent thumb-sucking. After the nurse provides instruction on this topic, which response by the parent indicates that teaching has been effective? "I'll wrap the baby's thumb in a bandage." "I'll give my baby a pacifier instead." "Thumb-sucking should be discouraged at age 12 months." "Sucking is important to the baby."
"Sucking is important to the baby." Explanation: Stating that sucking is the infant's chief pleasure indicates effective teaching. However, thumb-sucking may cause malocclusion if it persists after age 4. Many fetuses begin sucking on their fingers in utero and, as infants, refuse a pacifier as a substitute, so the parent who offers to give the infant a pacifier instead requires more teaching. A young child is likely to chew on a bandage, possibly leading to airway obstruction.
During discharge teaching with new caregivers, the caregivers express concern over a recent whooping cough outbreak. The caregivers asks when the client can receive the vaccine for whooping cough. The nurse states that which is the recommended immunization schedule for diphtheria, tetanus toxoids, and acellular pertussis (DTaP)? birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years birth, 3 months, 6 months, 12 months, and 4 to 6 years 2 months, 4 months, 6 months, 18 months, 4 to 6 years, and grade 9
2 months, 4 months, 6 months, 18 months, 4 to 6 years, and grade 9 Explanation: According to the Public Health Agency of Canada and the Centers for Disease Control, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, 4 to 6 years, and at grade 9.
A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay? proper methods for dealing with stressful situations such as crying infants referring the client for anger-management therapy upon discharge assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems when the infant is crying always offer the bottle or breast first
assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems Explanation: Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors. Educating the client about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. The nurse hasn't established that the mother is angry, so anger-management therapy may not be necessary. The infant may not be crying due to hunger; assessing the mother's coping will help provide the basis for teaching the essential skills.
A mother is concerned about her 9-year-old child's compulsion for collecting things. The nurse's explanation is based on the understanding that this behavior is related to the cognitive ability to perform which functions? formal operations tertiary circular reactions coordination of secondary schemata concrete operations
concrete operations Explanation: The school-aged child (age 7 to 11 years) who has achieved the cognitive abilities required to master concrete operations commonly collects various objects when learning to manipulate and classify these objects.Formal operations do not emerge until later (age 11 to 15 years).Coordination of secondary schemata is part of the sensorimotor phase of cognitive development (up to age 2 years).Tertiary circular reactions are part of the sensorimotor phase of cognitive development (up to age 2 years).
When assessing a child's cultural background, the nurse should keep in mind that physical characteristics mark the child as part of a particular culture. heritage dictates a group's shared values. cultural background usually has little bearing on a family's health practices. behavioral patterns are passed from one generation to the next.
behavioral patterns are passed from one generation to the next. Explanation: The nurse should keep in mind that a family's behavioral patterns and values are passed from one generation to the next. Cultural background commonly plays a major role in determining a family's health practices. Physical characteristics don't indicate a child's culture. Although heritage plays a role in culture, it doesn't dictate a group's shared values, and its effect on culture is weaker than that of behavioral patterns.
When reviewing the history of a 3-year-old child with Down syndrome, which behavior should the nurse interpret as a delay in early development? Select all that apply. lack of use of expressive language poor response to verbal commands onset of walking at age 20 months sitting up at age 6 months feeding self with finger foods by 9 to 12 months.
lack of use of expressive language poor response to verbal commands onset of walking at age 20 months Explanation: Being able to sit up at age 6 months is a typical developmental accomplishment. This skill could be expected to be delayed in a child with Down syndrome. Children with Down syndrome tend not to use expressive language. Children with Down syndrome commonly do not respond to verbal commands at a level appropriate to their chronological age. Walking, which normally occurs at about age 1 year, is almost always delayed in children with Down syndrome. Feeding self with finger foods is a typical skill attained by 9 to 12 months.
During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action? visualization of the ossicles through the tympanic membrane reddened tympanic membrane without discomfort light reflecting off the ear drum surface fine hairs in the auditory canal with dark brown wax
reddened tympanic membrane without discomfort Explanation: To perform an otoscopic examination on an adult, the nurse grasps the auricle of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the auricle and pulls it down to straighten the ear canal. Normal findings should include visualization of the ossicles through the tympanic membrane, fine hairs in the auditory canal with wax, and reflection of light off the light-gray or pearly white shiny ear drum. A reddened ear drum would indicate an infection with or without pain.
A client with rheumatoid arthritis tells the nurse that she feels "quite alone" in adjusting to changes in her lifestyle. Which response by the nurse will be most effective? recommending that the client discuss her feelings with her religious advisor referring the client and her husband for counseling to decrease her sense of isolation. suggesting that the client develop a hobby to occupy her time. telling the client about her community's arthritis support group.
telling the client about her community's arthritis support group. Explanation: The client should be encouraged to join the community arthritis support group so that she can share her feelings with others who are facing similar experiences with this chronic illness and can identify with her concerns. A hobby will not help her resolve her feelings of being alone. Seeking counseling or discussing her feelings with a minister may be helpful, but these activities will not necessarily help the client to understand that there are many individuals who must adjust their lifestyles because of arthritis and that she is not alone.
Which factors are major components of a client's general background history? allergies and socioeconomic status gastric reflex and the client's age bowel habits and allergies urine output and allergies
allergies and socioeconomic status Explanation: General background data consist of such components as age, allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.
A school-age child presents to the office for a routine examination. Given the child's developmental level, a nurse should give highest priority to: allowing the child to play with medical equipment before the examination begins. asking the parents to leave the room during the child's examination. allowing the child to change into a gown while the nurse isn't in the room. encouraging the child to hold a stuffed animal during the examination.
allowing the child to change into a gown while the nurse isn't in the room. Explanation: School-age children tend to be very modest. The nurse should allow them to change into gowns while the nurse isn't in the examination room. Children shouldn't have to take off their underwear for routine medical examinations. Playing with medical equipment is characteristic of younger children. The nurse shouldn't ask parents to leave the room unless the child requests that they not be present. A school-age child may feel too old to hold a stuffed animal during the examination.
A nurse is caring for a 4-year-old child on complete bed rest. What would be a priority nursing diagnosis when caring for this child? risk of altered nutrition (less than body requirements) related to lack of appetite risk of altered growth and development related to the effects of illness diversionary activity deficit related to lack of appropriate toys and peers sleep pattern disturbance related to routines of hospitalization
diversionary activity deficit related to lack of appropriate toys and peers Explanation: Ill children are at risk for sensory deprivation because of bed rest and confinement to a hospital room, where little sensory stimulation is provided. Hospitalized children tend to watch television for numerous hours, providing little interaction with others. There is nothing in the scenario to suggest sleep deprivation. Actual diagnoses always take priority over "risk of" diagnoses.
Which activity would be most appropriate to include in a playroom that will be used by children aged 13 months to 6 years? drawing and painting projects a group sing-along free play with adult supervision viewing cartoon videos
free play with adult supervision Explanation: Planning any single activity that will appeal to children from ages 13 months to 6 years is next to impossible because of the developmental differences found in such a wide age group. It would be best to allow these children to participate in free play with adult supervision. A group sing-along would be appropriate for preschoolers and school-aged children. However, toddlers have short attention spans and would most likely find it difficult to participate in a group activity, such as a sing-along. Although drawing and painting projects would be appropriate for preschoolers and school-aged children, toddlers have a tendency to put objects into their mouths. Therefore, drawing and painting projects would be inappropriate for this age group. Viewing cartoon videos would be inappropriate for young toddlers, who typically have short attention spans. Additionally, young toddlers may not understand the videos.
A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blister-like lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions? plaque pustules vesicles papules
vesicles Explanation: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.
A client is readmitted to the acute care facility. During the admission assessment, the client reports not taking the medication as prescribed. What is the best response by the nurse? "Why don't you take your medications as prescribed?" "Please tell me about how you take your medications?" "It is important to take all of your medications exactly as prescribed." "Did you have enough money to buy the medications?"
"Please tell me about how you take your medications?" Explanation: The best response by the nurse is "Please tell me about how you take your medications?" This allows the client to explain without fear of judgment how he or she takes the medications. Asking if the client has enough money to buy the medications may be insulting. Stating that it is important to take the medications does not allow the client a chance to explain any difficulties/issues experienced with taking the medication. Asking why the client does not take the medications as prescribed may make the client defensive.
A nurse is teaching a parenting class about how to prevent thrush (oral candidiasis). Which statement by a parent indicates more teaching is required? "I should rinse my child's glass after each use." "I should rinse my child's mouth after using a corticosteroid." "If my child uses a spacer with asthma medications, I need to rinse it after each use." "I will sterilize pacifiers."
"I should rinse my child's glass after each use." Explanation: A new glass should be used each time the child wants a drink. Thrush is a fungal infection. Children who regularly use a corticosteroid inhaler, use oral corticosteroids, or have received antibiotics disturbing normal flora are at risk. It can also occur chronically in children who have an immune disorder. To prevent reinfection parents should sterilize bottle nipples and pacifiers. Children with asthma should rinse their mouth well with water after using a corticosteroid, and if a spacer (reduces the amount of medicine in the mouth and throat) is used, it also needs to be rinsed.
The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do!" After the nurse teaches the parent about ways to manage this behavior, which statement by the parent indicates that the nurse's teaching was successful? "I'll allow her to have what she wants once in a while." "Next time she screams and throws her legs, I'll ignore the behavior." "I'll explain why she cannot have what she wants." "When she behaves like this, I'll tell her that she is being a bad girl."
"Next time she screams and throws her legs, I'll ignore the behavior." Explanation: The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child's behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering with the child's ability to develop a sense of autonomy.
A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1"Hold your breath for at least 10 seconds, then breathe in and out slowly." 2"Rinse your mouth." 3"Take off the cap and shake the inhaler." 4"Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." 5"Attach the spacer." 6"Press down on the inhaler once and breathe in slowly." SUBMIT ANSWER
"Take off the cap and shake the inhaler." "Attach the spacer." "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." "Press down on the inhaler once and breathe in slowly." "Hold your breath for at least 10 seconds, then breathe in and out slowly." "Rinse your mouth." Explanation: Using a spacer, especially with inhaled corticosteroid, can make it easier for the medication to reach the lungs; it can also prevent excess medication remaining in the mouth and throat, which can cause minor irritation. It is important for the client to empty the lungs, breathe in slowly, and hold the breath to draw as much medication into the lungs as possible. Rinsing after using a corticosteroid inhaler may help prevent irritation and infection; rinsing will also reduce the amount of drug swallowed and absorbed systemically.
After conducting a class for female adolescents about human reproduction, the nurse concludes that teaching has been effective when a student makes which statement? "I will not become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle." "Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy." "After an ovum is fertilized by a sperm, the ovum contains 21 pairs of chromosomes." "Sperm from a healthy male usually remain viable in the female reproductive tract for 96 hours."
"Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy." Explanation: Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexually active. Many people believe that the time interval is much longer and that they can wait until after intercourse to take steps to prevent conception. Without protection, pregnancy and sexually transmitted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of the menstrual cycle when the client is most likely to conceive. Using a 28-day cycle as an example, a couple should abstain from sex 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after sex, there is a possibility that fertilization can occur. Before fertilization, the ovum and sperm each contain 23 chromosomes. After fertilization, the conceptus contains 46 chromosomes unless there is a chromosomal abnormality.
Parents report that their child, age 4, resists going to bed at night. After instruction by the nurse, which statement by the parents indicates effective teaching? "We'll let the child fall asleep in our room, then move the child to their own room." "We'll read the child a story and let the child play quietly in bed until the child falls asleep." "We'll lock the child in their room if the child gets up more than once." "We'll play running games before bedtime to tire the child out, and then the child will fall asleep easily."
"We'll read the child a story and let the child play quietly in bed until the child falls asleep." Explanation: The parents stating that they'll read the child a story and let the child play quietly demonstrates effective teaching because spending time with the parents and playing quietly are positive bedtime routines that provide security and prepare a child for sleep. Saying that they will let the child fall asleep in the parent's room reflects ineffective teaching because the child should sleep in their own bed. Locking the door is frightening and may cause insecurity. Active play before bedtime stimulates the child and increases the time needed to settle down for sleep; therefore, a statement about running games would demonstrate ineffective teaching.
The mother says that the infant's primary care provider recommends certain foods, but the infant refuses to eat them after breastfeeding. How should the nurse suggest that the mother alter the feeding plan? Allow the infant to nurse for a few minutes and then offering solid foods. Offer dessert followed by some vegetables and meat. Offer breast milk as long as the infant refuses to eat solid foods. Mix pureed food with some breast milk in a bottle with a large-holed nipple.
Allow the infant to nurse for a few minutes and then offering solid foods. Explanation: It is typical for an infant just starting on solid foods to spit them out because the infant does not know how to swallow them. Also, the infant is hungry and is accustomed to having milk to satisfy that hunger. It is generally recommended that an infant be given some milk first and then offered solid foods. Offering dessert followed by vegetables and meat is inappropriate because the infant will learn to prefer the sweets first and then possibly refuse the vegetables and meats Offering breast milk as long as the infant refuses solid foods is inappropriate because an infant who fills up on breast milk will have no interest in the solids. Mixing pureed foods with breast milk is inappropriate because solid food should be given with a spoon. Also, using a large-holed nipple may cause the infant to choke from getting too much fluid at one time.
The nurse in the emergency department is caring for a preschool-age child with a fractured humerus. The child is crying and screaming, "I hate you!" Which action would be most appropriate? Ask the parents to discipline the child so that the physician can treat her. Reassure the parents that this a normal behavior under the circumstances. Tell the parents they will need to wait out in the lobby. Ask the charge nurse to assign this client to another nurse.
Reassure the parents that this a normal behavior under the circumstances. Explanation: Explaining to the parents that this is a normal reaction under the circumstances is most appropriate. The child's outburst is related to the child's fears of the unknown. The child is scared and anxious and needs the parents for support. Asking the parents to wait outside would only add to the child's fear and anxiety. The reaction is normal for a child her age and does not usually call for a change in staff assignments. Asking the parents to discipline their child for her behavior is inappropriate. The nurse needs to handle the situation.
A toddler is scheduled to have tympanostomy tubes inserted. When approaching the toddler for the first time, what should the nurse do? Pick up the toddler and take the child to the play area so that the mother can rest. Walk over and pick the toddler up right away so that the mother can relax. Hold the toddler so that the toddler becomes more comfortable. Talk to the mother first so that the toddler can get used to the new person.
Talk to the mother first so that the toddler can get used to the new person. Explanation: Toddlers should be approached slowly because they are wary of strangers and need time to get used to someone they do not know. The best approach is to ignore them initially and to focus on talking to the parents. The child will likely resist being held by a stranger, so the nurse should not pick up or hold the child until the child indicates a readiness to be approached or the mother indicates that it is okay.
The parents of a 6-year-old child tell the nurse that they are concerned about the child's tonsils. On inspection, the nurse notes that the tonsils are large but not reddened or inflamed. How does the nurse interpret this finding? a normal increase in lymphoid tissue the need for an antibiotic the need for tonsillectomy an acute viral infection of the tonsils
a normal increase in lymphoid tissue Explanation: Because lymphoid tissue develops rapidly in relation to size until age 10 to 11 years, lymphoid hyperplasia in the form of enlarged tonsils is normal until age 6 to 7 years. After this time, the tissue slowly atrophies. Enlarged tonsils are not surgically removed unless they become abscessed or compromise physiologic functioning. An antibiotic would be needed if the evidence suggested a bacterial infection. However, the tonsils are only enlarged, not reddened or inflamed, suggesting no infection.
Which child most needs a screening for scoliosis? a preschooler entering kindergarten a preadolescent client at the beginning of a growth spurt the infant of a mother with no prenatal care a toddler with a diet low in calcium and vitamin D
a preadolescent client at the beginning of a growth spurt Explanation: Preadolescents are at greatest risk for scoliosis because of the growth associated with this age group. Incidence is higher in girls than boys and increases during periods of rapid growth.No relationship exists between poor prenatal care and scoliosis.A toddler with a diet low in vitamin D and calcium is prone to develop rickets.The risk for scoliosis is greatest during adolescence, not for preschoolers. However, prior to entering school, preschoolers are required to have their immunizations up-to-date.
To help promote independence in the area of feeding for a school-aged child in skeletal traction, the nurse should help the child choose which meal? chicken noodle soup with crackers, grilled cheese sandwich, coleslaw, and chocolate milk in a carton chicken nuggets with sauce, carrot sticks, apple slices, ice cream sandwich, and milk in a carton spaghetti and meat sauce, cherry cobbler, and apple juice in a can carrot sticks, celery with cream cheese, roast beef and gravy, peas, gelatin, and milk in a cup
chicken nuggets with sauce, carrot sticks, apple slices, ice cream sandwich, and milk in a carton Explanation: To promote self-feeding, the nurse should provide the child with foods that can be eaten with the fingers or that do not spill easily. Fluids should be provided in containers with straws to prevent spills. Gravies, small round vegetables, and soups can easily spill from a spoon or fork when the child is eating in an unfamiliar position. Spaghetti can be very difficult for the child to eat.
Which of the following actions is correct when the student nurse assesses the fontanels of a 6-week-old infant? probing the fontanels firmly while the infant is prone on the table observing for the bulge of the fontanels while the infant cries palpating the fontanels gently while the infant sits on the parent's lap noting the shape of the fontanels while the infant lies flat
palpating the fontanels gently while the infant sits on the parent's lap Explanation: For the most accurate results, the student nurse should seat the infant upright to assess the fontanels and should perform this assessment when the infant is quiet. Pressure from postural changes or intense crying may cause the fontanels to bulge or seem abnormally tense. When the infant is in a recumbent position, the fontanel is less flat than it is normally, creating the false impression that intracranial pressure is increased.
