Saunders NCLEX_Developmental

Ace your homework & exams now with Quizwiz!

Preschool and School-Age

Toddlers

Adolescent

Early Adulthood to Later

The mother 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

ANS: 1. 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, 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.

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

ANS : 4. Punishment and reward Rationale: In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient 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.

The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should expect which statement that is aligned with the psychosocial expectations of this age? 1. "Being sick is scary." 2. "I know it hurts to die." 3. "I know I will be healthy soon." 4. "I know I am different than other kids."

ANS:

A mother of a 4-year-old expresses concern because her hospitalized child has begun thumb sucking. The mother states that this behavior began 2 days after hospital admission. Which response by the nurse is appropriate? 1. "It is best to ignore the behavior." 2. "Your child is acting like a baby." 3. "A 4-year-old is too old for this type of behavior." 4. "The primary health care provider will need to be notified."

ANS: 1. "It is best to ignore the behavior." Rationale: In the hospitalized preschooler, the best option is to accept regression if it occurs. Regression is most often a result of 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. When regression does occur, the best approach is to ignore it while praising existing patterns of appropriate behavior. Calling the primary health care provider is not necessary. Telling the mother that the child is acting like a baby or is too old for this type of behavior are inappropriate statements.

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories 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 relationship 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 understanding how individuals determine a moral code to guide their behavior. 5. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

ANS: 2. Moral development progresses in relationship 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 understanding how individuals determine a moral code to guide their behavior. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned. Rationale: 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 progresses in relationship to cognitive development and that a person'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 orientation), the child conforms to rules to obtain rewards or have favors returned.

The clinic nurse provides information to the mother of a toddler regarding toilet training. Which statement by the mother indicates a need for further information regarding toilet training? 1. "Bladder control usually is achieved before bowel control." 2. "The child should not be forced to sit on the potty for long periods." 3. "The ability of the child to remove clothing is a sign of physical readiness." 4. "The child will not be ready to toilet train until the age of about 18 to 24 months."

ANS: 1. "Bladder control usually is achieved before bowel control." Rationale: Bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is 1 of the physical signs of readiness for toilet training. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between the ages of 18 and 24 months.

The mother of a 5-year-old child tells the nurse that the child scolds the floor or a table if she hurts herself on the object. The nurse educates the mother according to Piaget's theory of cognitive development and its terminology and definitions. Which statement by the mother indicates that the teaching has been effective? 1. "This is an example of animism." 2. "This is an example of egocentric speech." 3. "This is an example of object permanence." 4. "This is an example of global organization."

ANS: 1. "This is an example of animism." Rationale: Animism means that all inanimate objects are given living meaning. Egocentric speech occurs when the child talks just for fun and cannot see another's point of view. Object permanence, the realization that something out of sight still exists, occurs in the later phases of the sensorimotor stage of development. Global organization means that if any part of an object or situation changes, the whole thing has changed. Options 2 and 4 occur during the preoperational stage.

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

ANS: 1. Crusting Rationale: 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.

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.

ANS: 1. Set limits on the child's behavior. 4. Provide a simple explanation of why the behavior is unacceptable. Rationale: According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying 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.

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 environment. 3. The child is able to classify, order, and sort facts. 4. The child learns to think in terms of past, present, and future.

ANS: 1. The child has the ability to think abstractly. Rationale: 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 operational stage. Option 4 identifies the preoperational stage.

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student 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.

ANS: 1. This stage is associated with toilet training. Rationale: In 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.

ANS: 2. "I know it hurts to die." Rationale: A preschool-age child begins to conceptualize the death process as involving physical harm. An adolescent expresses fear, withdrawal, and denial, noted in option 1. A child from birth to 2 years of age is unable to grasp the concept of illness and death, which is reflected in the statement in option 3. A school-age child begins to understand that something is wrong, which is noted in option 4.

The clinic nurse has provided instructions about dental care for toddlers to the mother of a 2-year-old child. Which statement, if made by the mother, indicates a need for further instruction? 1. "It is best to substitute sweets or snacks with food items such as cheese." 2. "Proper dental care is not necessary for a toddler until the permanent teeth erupt." 3. "My child should have the first dental exam at some point after the second birthday." 4. "I do not need to be concerned if the child swallows some toothpaste while brushing the teeth."

ANS: 2. "Proper dental care is not necessary for a toddler until the permanent teeth erupt." Rationale: The nurse should instruct the mother that proper dental care for a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries. The first dental visit should be made after the first primary tooth erupts and no later than 30 months of age. It will not hurt the child if some of the toothpaste is swallowed.

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

ANS: 2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset Rationale: Anatomical changes to the eye affect the individual's visual ability, leading to potential problems with 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 memory may 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.

An older client is admitted to the hospital with a diagnosis of malnutrition. Other than cognitive status, what other factors can increase the risk of malnutrition and dehydration? Select all that apply. 1. Past profession 2. Physical fatigue 3. Limited mobility 4. Sensory decreases 5. Inadequate dental care 6. Family history of malnutrition

ANS: 2. Physical fatigue 3. Limited mobility 4. Sensory decreases 5. Inadequate dental care Rationale: Other factors besides cognitive status that can increase the risk of malnutrition and dehydration include physical fatigue, limited mobility, sensory decreases, and inadequate dental care. Past profession and family history of malnutrition do not increase one's risk for malnutrition.

The nurse is assigned to care for a hospitalized toddler. The nurse plans care, knowing that what should be the highest priority? 1. Providing a consistent caregiver 2. Protecting the toddler from injury 3. Adapting the toddler to the hospital routine 4. Allowing the toddler to participate in play and diversional activities

ANS: 2. Protecting the toddler from injury Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Although consistency, adaptation, and diversion are important, protection from injury is the highest priority.

The nurse is preparing to perform a pediatric physical examination. The child refuses to sit on the examining table, screams when the nurse attempts to perform the assessment, and does not make eye contact. What is the most appropriate initial nursing action? 1. Refrain from complimenting the child. 2. Talk to the parent while ignoring the child. 3. Offer a prolonged explanation about the assessment. 4. Use a demanding approach when discussing expected behavior.

ANS: 2. Talk to the parent while ignoring the child. Rationale: When performing a pediatric physical examination, if signs of readiness (i.e., sitting on the examining table rather than the parent's lap, allowing physical touch, and making eye contact) are not observed, the nurse should talk to the parent while essentially ignoring the child, then gradually focus on the child or favorite object, such as a doll, and make complimentary remarks about the child, such as about appearance, dress, or a favorite object. If the child refuses to cooperate, the nurse should use a direct approach regarding expected behavior and avoid prolonged explanations about the examining procedure.

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 development 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."

ANS: 3. "At this age, the child is developing his own personality." Rationale: 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 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."

ANS: 3. "I drink hot chocolate before bedtime." Rationale: 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 developing a plan of care for a 4-year-old child scheduled for a renal biopsy. What developmental characteristic of this child should the nurse consider? 1. Masturbation is common in this age group. 2. Body image may be a concern for the child. 3. Fears of mutilation may be present in the child. 4. The urination pattern will cause embarrassment for the child.

ANS: 3. Fears of mutilation may be present in the child. Rationale: During the preschool years, a child's fears of separation and mutilation are great because the child is facing the developmental task of trusting others. As the child gets older, fears about virility and reproductive ability may surface. Masturbation is most common in the toddler age group as children discover their genital organs. Body image is a concern for the adolescent.

A mother tells the nurse in a pediatrician's office that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse explores which suggestion with the mother to decrease the children's sense of isolation and fear? 1. Instruct the children never to cook. 2. Let the children play in neighborhood homes. 3. Find community after-school programs or activities. 4. Have the children call the mother at work every hour.

ANS: 3. Find community after-school programs or activities. Rationale: In most communities, free or low-cost after-school programs or activities are available that minimize the amount of time during which school-age children are at home alone. These programs should include adult supervision, which is needed by school-age children. Prohibiting cooking enhances safety but does not address isolation and fear. Neighborhood play is inadequate because no one is assuming responsibility for the after-school safety of the children; no formal agreement to provide child care has been made with the other families. Calling the mother at work hourly may reassure the mother that the children are home and safe, but it does not address feelings of isolation and fear.

The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. Which is the correct interpretation of the behavior? 1. The child is withdrawn. 2. The child is self-centered. 3. The child exhibits detachment. 4. The child has adjusted to the hospital setting.

ANS: 3. The child exhibits detachment. Rationale: The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In detachment, when the parents return, the child becomes more interested in the environment and new persons (seemingly unaware of the lost parents), friendly with the staff, and interested in developing superficial relationships. In the stage of protest, the child may cry, scream, and search for a parent. In the stage of despair, the child may be withdrawn and uninterested in the environment. That the child is withdrawn, is self-centered, or has adjusted to the hospital setting are incorrect interpretations of the child's behavior.

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 his or her (adolescent) same age group.

ANS: 4. Allow the client to interact with others in his or her (adolescent) same age group. Rationale: 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.

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

ANS: 4. Allowing the client to choose 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. 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.

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

ANS: 4. Crayons and a coloring book Rationale: 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 is most appropriate for the adolescent. Large picture books are most appropriate for the infant.

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.

ANS: 4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center. Rationale: 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 at a well-baby clinic is assessing the motor development of a 24-month-old child. On the basis of the age of the child, the nurse expects to note what as the highest-level developmental milestone? 1. The child snaps large snaps. 2. The child builds a tower of 2 blocks. 3. The child puts on simple clothes independently. 4. The child opens a door by turning the doorknob.

ANS: 4. The child opens a door by turning the doorknob. Rationale: A 24-month-old child should be able to open a door using the doorknob. At age 15 months, the nurse should expect that the child could build a tower of 2 blocks. At age 30 months, the child should be able to snap large snaps and put on simple clothes independently.

A 4-year-old child diagnosed with leukemia is hospitalized 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.

ANS: 1. Encourage the child's parents to stay with the child. Rationale: Although the preschooler already may be spending some time away from parents at a day-care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want 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 may be immunocompromised and at risk for infection.

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.

ANS: 1. Provide swaddling. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. Rationale: 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 containing milk, juice, soda pop, sweetened water, or another sweet liquid because of the risk of nursing (bottle-mouth) caries.

The nurse notes that a 6-year-old child does not recognize that objects exist 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 pediatrician. 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.

ANS: 1. Report the observation to the pediatrician. Rationale: According to Jean Piaget's theory of cognitive development, it is normal for the infant or toddler not to recognize that objects continue to be in existence 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 pediatrician. Options 2, 3, and 4 delay necessary follow-up and treatment.

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.

ANS: 4. Inform the child of bedtime a few minutes before it is time for bed. Rationale: 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 pediatric nurse is caring for a hospitalized toddler. What does the nurse determine is the most appropriate play activity for the toddler? 1. Listening to music 2. Playing peek-a-boo 3. Hand sewing a picture 4. Playing with a push-pull toy

ANS: 4. 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. Push-pull toys are appropriate for this age. Listening to music is most appropriate for an adolescent. Playing peek-a-boo is most appropriate for an infant. Hand sewing a picture is most appropriate for a school-age child.

A 15-year-old is injured and sustains a fractured jaw. The fractured jaw has been surgically wired, and the primary health care provider (PHCP) has prescribed a full liquid diet. Which nursing action would best promote compliance and provide an adequate nutrient value with the full liquid diet for this teenager? 1. Offer chocolate milkshakes between meals. 2. Explain the importance of good nutrition to the teenager. 3. Offer commercial nutritional supplements 4 to 6 times per day. 4. Ask the teenager for food preferences and liquefy these foods using a blender.

ANS: Rationale: A 15-year-old may have difficulty maintaining compliance with a diet that is only liquids. To encourage compliance, it is important to have the teenager participate in as much decision making about the diet as possible. Although liquefied foods may be unappealing under many circumstances, the nutrient value is unchanged. The teenager will have an opportunity to "eat" the same foods that he or she was eating before the jaw fracture. Providing chocolate milkshakes between meals may be beneficial but does not offer the teenager any choices. Teenagers may or may not respond to reasoning and explanations of the importance of good nutrition. Commercial supplements also are beneficial nutritional sources but will not be effective unless the client is willing to drink them.

The nurse is caring for a 14-year-old girl who is hospitalized and has been placed in traction using Crutchfield tongs. The child is having difficulty adjusting to the prolonged hospital confinement. Which nursing action would be appropriate to meet the child's needs? 1. Let the child wear her own clothing when friends visit. 2. Allow the child to have her hair dyed if the parent agrees. 3. Allow the child to play loud music in the hospital room. 4. Allow the child to keep the shades closed and the room darkened at all times.

ANS: 1. Let the child wear her own clothing when friends visit. Rationale: Adolescents need to identify with their peers and have a strong need to belong to a group. They prefer to dress like the group and wear similar hairstyles, which are different from their parents'. The child should be allowed to wear her own clothes to feel a sense of belonging to the group. Because Crutchfield tongs require the use of skeletal pins, hair dye is not appropriate. Loud music may disturb others in the hospital. The child's request for a darkened room may indicate a problem with depression that may need further evaluation and intervention.

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to the anal stage? 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.

The mother of a 16-year-old tells the nurse that she is concerned because her child sleeps about 8 hours every night and until noon every weekend. Which nursing response is most appropriate? 1. "The child should not be staying up so late at night." 2. "Adolescents need that amount of sleep every night." 3. "If the child eats properly, that should not be happening." 4. "The child probably is anemic and should eat more foods containing iron."

ANS: 2. "Adolescents need that amount of sleep every night." Rationale: An adolescent needs about 8 hours of sleep per night. During this age, with an increase in social activities, school commitments, and possibly work activities, it is important that the adolescent receive enough sleep at night. Nothing in the question indicates that the child is staying up at night. Adolescents need 8 hours of sleep each night, so diet is not a concern. Although anemia can cause fatigue, there is nothing in the question to indicate that the child has anemia, and the nurse should not attempt to diagnose a medical condition.

A 2-year-old child has been admitted to the hospital for management of pneumonia. The child is placed in an oxygen tent. Taking into consideration the child's age and developmental level and the treatment being administered, which statement is appropriate for the nurse to make to the parents? 1. "He can play in the tent with his blocks and plush stuffed animals." 2. "You can sit next to him and hold his hand through the tent, but he needs to remain inside of it." 3. "At his age, separation anxiety is high, so bringing in the wool blanket that he usually sleeps with is a good idea." 4. "Before you leave for the night, it is a good idea to rock him to sleep. He can be out of the tent for up to 60 minutes without any consequences."

ANS: 2. "You can sit next to him and hold his hand through the tent, but he needs to remain inside of it." Rationale: Oxygen therapy is an important component of management of pneumonia and is effective only if it is used appropriately. It is important to maintain the toddler in the oxygen environment at all times. With the addition of oxygen therapy, the hospitalized toddler is at risk for increased anxiety. Attachment is critical to optimal growth and development of children, particularly in the infant and toddler years. Therefore, sitting with the child and holding the child's hand is important. Wool blankets, stuffed toys, and many toy cars can produce sparks, which could lead to an oxygen tent's catching fire. It is important to educate parents and family members not to bring these types of objects to the hospital.

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?

ANS: 2. Allow the bottle if it contains water. Rationale: 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 at a well-baby clinic is providing nutrition instructions to the mother of a 1-month-old infant. What instruction should the nurse give to the mother? 1. Introduce strained fruits 1 at a time. 2. Breast milk or formula is the main food. 3. Introduce strained vegetables 1 at a time. 4. Offer rice cereal mixed with breast milk or formula.

ANS: 2. Breast milk or formula is the main food. Rationale: Breast milk or formula is the main food throughout infancy. Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats are introduced 1 at a time and can begin at 6 months of age.

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

ANS: 2. Increased risk for digoxin toxicity Rationale: 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 nurse is observing a caregiver minimize misbehavior when a child is playing with an excessively noisy toy. The nurse recognizes that further instruction is needed about the appropriate way to do this if the caregiver takes which action? 1. Tells the child, "Put that toy down." 2. Instructs the child, "Don't touch that toy." 3. Interacts with the child in a quiet, calm voice. 4. Offers the child a quiet toy in exchange for the noisy one.

ANS: 2. Instructs the child, "Don't touch that toy." Rationale: Minimizing misbehavior includes teaching desirable behavior through example, such as using a quiet, calm voice rather than screaming. Requests for appropriate behavior should be phrased positively, such as "Put that toy down" rather than "Don't touch that toy." Alternatives, such as offering a quiet toy in exchange for one that is excessively noisy, should be offered in response to annoying actions.

The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?

ANS: 2. Uses a cup to drink Rationale: By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4 years, 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 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

A 6-month-old infant is admitted to the hospital. The nurse weighs the infant and notes that the infant's weight is 14 pounds. Which statement by the mother indicates that further teaching is needed?

ANS: 3. "I will have to increase his milk intake because he is not gaining enough weight." Rationale: Newborns double their birth weight at 5 to 6 months of age and triple it by 1 year. Therefore, options 1, 2, and 4 are correct statements. Option 3 indicates the need for further teaching.

The nurse at a well-baby clinic is assessing the language and communication developmental milestones of a 4-month-old infant. On the basis of the age of the infant, what should the nurse expect to note as the highest-level developmental milestone? 1. Cooing sounds 2. Use of gestures 3. Babbling sounds 4. Increased interest in sounds

ANS: 3. Babbling sounds Rationale: Babbling sounds are common between the ages of 3 and 4 months. In addition, at this age crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. The use of gestures occurs between 9 and 12 months. An increased interest in sounds occurs between 6 and 8 months.

ANS: 4. Punishment and reward Rationale: In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient 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.

Which would be the highest expected growth and development occurrence at 12 months of age for an infant who has had appropriate growth assessed at each well-child visit 1. Imitates sounds 2. Smiles spontaneously 3. Sits steadily unsupported 4. Walks holding on to someone's hand

ANS: 4. Walks holding on to someone's hand Rationale: Growth and development are sequential and predictable. One task builds on another. Mastery of a lower-level task must occur before higher-level tasks are completed. At 12 months a child can walk holding on to someone's hand. Smiling, imitating sounds, and sitting steadily unsupported begin at 6 months of age.

The nurse in the well-baby clinic has provided instructions regarding dental care to the mother of a 10-month-old child. Which statement by the mother indicates a need for further instruction? 1. "I need to limit the amount of concentrated sweets." 2. "I need to use fluoride supplements if the water is not fluoridated." 3. "I need to start dental hygiene as soon as the primary teeth erupt." 4. "I can coat a pacifier with honey during the day as long as I do not give my child a bottle at nap or bedtime."

ANS: "I can coat a pacifier with honey during the day as long as I do not give my child a bottle at nap or bedtime." Rationale: The practice of coating pacifiers with honey or using commercially available hard-candy pacifiers is discouraged. Besides being cariogenic, honey also may cause botulism, and broken-off pieces of the candy pacifier may be aspirated. In addition, sweet milk or other fluids such as juice in a bottle taken at naptime or bedtime will bathe the teeth, producing caries. Fluoride, an essential mineral for building caries-resistant teeth, is needed, usually beginning at 6 months of age if the infant does not receive adequate fluoride content. A diet that is low in sweets and high in nutritious foods promotes dental health.

The nurse is caring for a 4-year-old child. When experiencing pain, the nurse anticipates which about the child? Select all that apply. 1. Views pain as a punishment 2. Verbalizes the reason for the pain 3. Blames someone else for the pain 4. Believes pain will disappear magically 5. Fears losing control during the painful episode 6. Will be able to explain the sequence of events leading to the pain

ANS: 1. Views pain as a punishment 3. Blames someone else for the pain 4. Believes pain will disappear magically Rationale: Children from the ages of 2 to 7 years experience preoperational thought. Concepts of pain within this stage include viewing pain as punishment for wrongdoing, thinking that pain will disappear magically, believing that someone else is accountable for the pain, and relating to pain primarily as a physical and concrete experience. Verbalizing the reason for the pain, fearing loss of control due to the pain, and explaining the events that led to the pain are not associated with concepts about pain for a child of this age.

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

ANS: 2. Booster seat Rationale: All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 ft, 9 in 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 infant-only seat or a convertible seat until they weigh at least 20 lb (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 20 lb (9 kg) and 1 year of age.

A 10-year-old child has been diagnosed with type 1 diabetes mellitus, and the nurse prepares to educate the family. The child is very active socially and often is away from the parents. Which is the best focus of the nurse's teaching for this client? 1. The parents are instructed to always be available to monitor the child's insulin requirements. 2. The child is taught how to monitor insulin requirements and how to self-administer the insulin. 3. All of the friends and family involved with the child's activities should be involved in monitoring the child's insulin requirements. 4. The child's schoolteacher needs instruction on how to assist the child to monitor insulin requirements and how to oversee the child's self-administration of insulin.

ANS: 2. The child is taught how to monitor insulin requirements and how to self-administer the insulin. Rationale: Most children 9 years of age and older can understand the principles of monitoring their own insulin requirements. They usually are responsible enough to determine the appropriate intervention needed to maintain their health. Parents, friends, and family cannot always be available. The schoolteacher will not take responsibility for health care interventions such as this one.

The nurse in the pediatric unit is admitting a 2½-year-old child. Which stage in Erikson's psychosocial stages of development should the nurse plan care around? 1. Trust versus Mistrust 2. Initiative versus Guilt 3. Industry versus Inferiority 4. Autonomy versus Shame and Doubt

ANS: 4. Autonomy versus Shame and Doubt Rationale: A 2½-year-old child, a toddler, is in the Autonomy versus Shame and Doubt stage. In this stage the toddler develops a sense of control over the self and bodily functions. Trust versus Mistrust characterizes the stage of infancy. Initiative versus Guilt characterizes the preschool age. Industry versus Inferiority characterizes the school-age child.

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 pediatrician. 4. Elevate the head of the bed to 90 degrees.

ANS: 2. Document the finding. Rationale: 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 pediatrician, or elevate the head of the bed to 90 degrees.

Which would be the highest expected growth and development occurrences at 9 months of age for an infant who has had appropriate growth assessed at each well-child visit? Select all that apply. 1. Will smile spontaneously 2. Rolls over in both directions 3. Able to sit steadily unsupported 4. Should be able to say "mama" and "dada" 5. Will pull up and stand for several seconds holding on to furniture 6. Will be able to pick up small pieces of food when placed in a high chair 1. Will smile spontaneously 2. Rolls over in both directions 3. Able to sit steadily unsupported 4. Should be able to say "mama" and "dada" 5. Will pull up and stand for several seconds holding on to furniture 6. Will be able to pick up small pieces of food when placed in a high chair

ANS: 4. Should be able to say "mama" and "dada" 5. Will pull up and stand for several seconds holding on to furniture 6. Will be able to pick up small pieces of food when placed in a high chair Rationale: Growth and development are sequential and predictable. One task builds on another. Mastery of a lower-level task must occur before higher level tasks are completed. A child must be able to roll over before sitting alone and before beginning to creep and crawl. After mastering crawling, the infant (9 months of age) will pull up and hold on to furniture. Sitting steadily unsupported begins soon after 6 months. The pincer grasp is mastered by 12 months but begins refinement at 9 months. Once this is accomplished, the infant will begin grasping a spoon. Language development begins at 6 months with imitating sounds and smiling spontaneously, progressing to saying "mama" and "dada" at 9 months of age.

The registered nurse (RN) is educating a new RN on the "law and order orientation" found in level 2 of Kohlberg's theory of moral development. Which statement by the new RN indicates that the teaching has been effective? 1. "An example of this is: If I skip down the hall, will the teacher be mad at me?" 2. "An example of this is: We will spend time talking about the activities for the week." 3. "An example of this is: I don't like it when you yell while I am talking to my friend. Here are some activities to do until I am finished talking." 4. "An example of this is: If you do all of your classwork today without bothering others in the class, you will get an extra 'seed' for your good behavior garden."

ANS: 1. "An example of this is: If I skip down the hall, will the teacher be mad at me?" Rationale: In the law and order orientation of Kohlberg's theory, the child has more concern with society as a whole, and emphasis is on obeying laws to maintain social order. The child wants to be considered "good" by persons whose opinions matter to him or her. The correct choice is the only option that reflects this criterion. All other options are unrelated to the law and order orientation.

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."

ANS: 1. "We will be sure not to leave hot liquids unattended." Rationale: 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.

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial 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.

ANS: 1. Allow the newborn infant to signal a need Rationale: 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.

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. While preparing the nursing care plan for this child, which factor should the nurse take into consideration? 1. This surgery is taking place at a time when fears of separation are great. 2. This surgery is taking place at a time when sibling rivalry will cause regression to occur. 3. This surgery is taking place at a time when concern over size and function of the penis is present. 4. This surgery is taking place at a time when embarrassment about voiding irregularities is common.

ANS: 1. This surgery is taking place at a time when fears of separation are great Rationale: At the age of 1 year, a child's fears of separation are great because the child is facing the developmental task of trusting others. No data in the question allow one to determine that siblings exist. Options 3 and 4 might be issues if the child were older.

The mother of a toddler informs the nurse that her child has frequent temper tantrums. The nurse should instruct the mother to implement which measure to deal with the temper tantrums? 1. Restrain the child. 2. Ignore the behavior. 3. Leave the child unattended. 4. Allow the child to bang his head.

ANS: 2. Ignore the behavior. Rationale: During temper tantrums the mother should ignore the behavior, providing that the behavior is not injurious to the child, such as banging the head on the floor. The mother should continue to be present to provide a feeling of control and security to the child once the tantrum has subsided.

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 per minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the pediatrician. 4. Reassess the respiratory rate in 15 minutes.

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

The nurse is instructing the caregiver of a child about reprimanding the child. The nurse recognizes that additional teaching is needed if the caregiver makes which statement to the child? 1. "I like it when you obey." 2. "I need you to listen to me." 3. "You need to stop hitting your sister." 4. "I don't like it when you hit your sister."

ANS: 3. "You need to stop hitting your sister." Rationale: When reprimanding children, the person reprimanding should focus only on the misbehavior, not on the child. "I" messages rather than "you" messages should be used to express personal feelings without accusation. An "I" message attacks the behavior, not the child.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees 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. A woman who has advanced Parkinson's disease 4. A woman who has early diagnosed Lyme disease

ANS: 3. A woman who has advanced Parkinson's disease Rationale: 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.

An infant is being seen in the pediatrician's office for a 2-month-old well-child visit. The nurse encourages the mother to allow the infant to suck on a pacifier during a routine immunization. The nurse explains to the mother that the child is at which stage of Piaget's cognitive development? 1. Trust development 2. Autonomy development 3. Sensorimotor development 4. Preconceptual development

ANS: 3. Sensorimotor development Rationale: Piaget's first stage of cognitive development is referred to as the sensorimotor stage. In this stage, infants and young toddlers use mainly senses and movement to begin to understand and control their environment. Preconceptual is the second stage after sensorimotor development. Development of trust and autonomy identify Erikson's stages of psychosocial, not cognitive, development.

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What should the nurse tell the AP 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.

ANS: 3. They respond to low-pitched tones. Rationale: Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. 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. Options 1, 2, and 4 are not accurate characteristics related to aging.

The clinic nurse assesses the communication patterns of a 5-month-old infant. Which assessment finding should lead the nurse to determine that the infant is demonstrating the highest level of developmental achievement expected? 1. Coos when comforted 2. Links syllables together 3. Uses monosyllabic babbling 4. Uses simple words such as mama

ANS: 3. Uses monosyllabic babbling Rationale: Using monosyllabic babbling occurs between 3 and 6 months of age. Cooing begins at birth and continues until 2 months of age. Linking syllables together when communicating occurs between 6 and 9 months of age. Using simple words such as mama occurs between 9 and 12 months of age.

The 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 most appropriate intervention? 1. Keeping the infant as quiet as possible 2. Restraining the infant to prevent dislodging of tubes 3. Placing small toys in the crib to provide stimulation for the infant 4. Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization

ANS: 4. Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization Rationale: A 10-month-old is in the Trust versus Mistrust stage of psychosocial development according to Erikson. The infant is developing a sense of self, and the nurse should 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 provide sensory stimulation. Keeping the infant as quiet as possible will not provide sensory stimulation. The infant should not be restrained. Placing small toys in the crib is an unsafe action.

Saunders NCLEX_Developmental

Related study sets

CEH

Chapter 2 Test 1 Vocabulary and Concepts

Databases

CEH All Chapters Practice Questions

Science Topic 3 Lesson 3

Classroom management

MGMT

Chapter 3

chem review quiz 6

Chapter 19 section 1 - Europeans Explore the East

Project Management Exam 1 practice

SPM Speaking - Pros and Cons of Working Part Time as a Student

NUR415 Remediation Qs (Session 1- Bleeding & Cardiovascular)

French Final Exam study guide

MGMT 3080 Test 2

Macroeconomics 1040 Final Exam pt.2

THE SPECIAL SENSES

Hematology & Immunology Peds NCLEX ?'s

Chapter 14: Perioperative Care

Musculoskeletal Trauma and Orthopedic Surgery