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156 Cards in this Set
- Front
- Back
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grain to mg? |
1 grain=60mg
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What is a microdrip?
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60gtt/mL
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How do you calculate fluid maintenance on child less than 10kg?
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100mL/kg
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How do you calculate fluid maintenance on child >10kg but less than 20kg?
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1000mL for the 1st 10mg + 50mL/kg for each kg >10 and less than 20.
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How do you calculate fluid maintenance on child >20kg?
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1500mL for the 1st 20mg + 20mL/kg for each kg >20.
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5.
Which of the following has had the greatest impact on reducing infant mortality in the United States? A. Improvements in perinatal care B. Decreased incidence of congenital abnormalities C. Better maternal nutrition D. Improved funding for health care |
***a. The improvements in perinatal care, in particular respiratory care and care of the mother-baby dyad prior to delivery, have had the greatest impact (pp. 2-3).
b. There has been a decrease in some congenital anomalies such as spina bifida, but this is not the greatest impact. c. This has had a positive influence but not the greatest overall impact. d. Changes in funding have not had the greatest impact. |
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4.
When the nurse uses a standard nursing care plan as a guide in planning care for a hospitalized child, which of the following should be eliminated? A. Expected outcome/goal B. Dependent nursing functions C. Problems not pertinent to the child/family D. Potential health problems of the child/family |
***c. These are general problems/interventions that may occur. To create an individualized plan of care, the nurse eliminates the nonrelevant material and concentrates on specific information pertinent to the child and family in question (p. 19).
a. Expected outcomes/goals would be made specific to the child and family and remain part of the care plan. b. Dependent nursing functions made specific to the child and family would remain. d. Potential health problems pertinent to the child and family would remain. |
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Evidence-based practice, a current health care trend, is best described as:
A. gathering evidence of mortality and morbidity in children. B. meeting physical and psychosocial needs of the child and family in all areas of practice. C. using a professional code of ethics as a means for professional self-regulation. D. questioning why something is effective and whether there is a better approach. |
****d. Evidence-based practice helps focus on measurable outcomes and the use of demonstrated, effective, interventions and questions whether there is a better approach.
a. This will assist the nurse in determining areas of concern and potential involvement. b. It is not possible to meet all needs of the family and child in all areas of practice. The nurse is an advocate for the family. c. This is part of the professional role and licensure. |
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2.
The etiology component of the nursing diagnosis describes which of the following? A. Projected changes in an individual's health status, clinical conditions, or behavior B. Individual's response to health pattern deficits in the child, family, or community C. Cluster of cues and/or defining characteristics that are derived from patient assessment and indicate actual health problems D. Physiologic, situational, and maturational factors that cause the problem or influence its development |
***d. This is the definition of etiology, the second component of the nursing diagnosis.
a. These are the outcomes or goals that are established. b. This is the definition of the problem statement, the first component of the nursing diagnosis. c. This is the third part of the nursing diagnosis, the signs and symptom |
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3.
The role of the pediatric nurse is influenced by trends in health care. Which of the following is the greatest trend in health care? A. Primary focus on treatment of disease or disability B. National health care planning on a distributive or episodic basis C. Accountability to professional codes and international standards D. Shift of focus to prevention of illness and maintenance of health |
***d. Prevention is the current focus of health care, one in which nursing plays a major role.
a. Traditionally this is the role of the physician. b. This is not a major trend. c. This is an established responsibility, not a trend. |
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1.
The nurse is setting up a community safety program about car seats. What level of prevention is this? A. Primary B. Tertiary C. Secondary D. Environmental |
***a. Car seat safety focuses on health promotion and the prevention of disease or injury, which is primary prevention (p. 25).
b. Tertiary prevention focuses on optimizing function for children with chronic illness and disabilities. c. Secondary prevention involves screening and early diagnosis of diseases. d. This is not a level of prevention. |
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Which of the following is defined as a group of people living in a specific geographic area?
A. Culture B. Community C. Target population D. Individual countries and states |
***b. This is the definition of a community (p. 23).
a. Culture refers to a group of people who share a common language and traditions. c. This is a narrowly defined group toward which the nurse can direct actions to improve health. d. These are geopolitical boundaries. |
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Studies of families with only one child indicate that only children:
A. tend to be selfish. B. are similar to firstborn children. C. are less stimulated toward achievement. D. grow up lonely and dependent on other adults. |
***b. As only children, they have many of the characteristics of firstborn children (p. 40).
a. and d. These attributes are not associated with birth order. c. This is characteristic of middle children. |
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The parents of a young child ask the nurse for suggestions on how to discipline. When discussing the use of "time-outs," which of the following should the nurse include?
A. Send the child to his or her room if the child has one. B. If the child cries, refuses, or is more disruptive, try another approach. C. Select an area that is safe and nonstimulating, such as a hallway. D. General rule for length of time is 1 hour per year of age. |
***c. The area must be nonstimulating and safe. The child becomes bored in this environment and then changes behavior to rejoin activities (p. 46).
a. The child's room may have toys and other equipment and activities that may negate the effect of being separated from the family activities. b. When the child engages in such behavior, the child should be reminded that the time-out begins when the child quiets. d. The general rule is 1 minute per year. An hour per year is excessive. |
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Which of the following is appropriate advice for parents who are preparing to tell their children about their decision to divorce?
A. Avoid crying in front of children. B. Avoid discussing the reason for the divorce. C. Give reassurance that the divorce is not the children's fault. D. Give reassurance that the divorce will not affect most aspects of the children's lives. |
***c. Parents, if able, should hold and touch children and reassure them that the children are not the cause of the divorce (p. 51).
a. Parents can cry in front of children; it may give the children permission to do the same. b. Parents should provide the reasons for the divorce in a manner the children will understand. d.This would most likely be false reassurance because many aspects will change. |
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Which of the following is descriptive of family system theory?
A. Family is viewed as the sum of individual members. B. Change in one family member cannot create a change in other members. C. Individual family members are readily identified as the source of a problem. D. When the family system is disrupted, change can occur at any point in the system. |
***d. Family systems theory describes an interactional model. Any change in one member will create change in others (p. 31).
a. Although the family is the sum of the individual members, family systems theory focuses on the number of dyad interactions that can occur. b. Change in any family member will affect other members of the family. c. The interactions are considered to be the problem, not the individual members. |
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Which of the following is descriptive of homosexual or gay-lesbian families?
A. Nurturing environment is lacking. B. Stability needed to raise healthy children is lacking. C. Sexual identities of children are at risk. D. Family environment can be just as healthy as any other. |
d. Although these families may be different from heterosexual families, the environment can be as healthy as any other (p. 37).
a. and b. These are reflective on the parents and family, not the type of family. c. There is little evidence to support this. |
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The most overwhelming adverse influence on health is which of the following?
A. Race B. Customs C. Socioeconomic status D. Genetic constitution |
3. A higher percentage of lower-class individuals have some health problem at any one time than other individuals in different classes. There is a high correlation between poverty and poor nutrition (p. 64).
1. Although children of different racial groups have differing health issues, socioeconomic status is a key predictor. 2. Customs do not usually have an adverse effect on health. 4. On a population basis, this is not an overwhelming adverse influence. |
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The nurse is caring for a dying boy whose religion is Islam (Muslim/Moslem). Which of the following is an important nursing consideration related to his impending death and religion?
A. There are no special rites. B. There are specific practices to be followed. C. The family is expected to "wait" away from the dying person. D. Baptism should be performed if it has not been done previously. |
2. Islam has specific rituals for bathing and wrapping the body in cloth before it is to be moved (p. 73).
1. Nurse should contact someone from the person's mosque to assist. 3. Family may be present. 4. No baptism is performed at this time. |
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The nurse is planning care for a patient with an ethnic background different from the nurse's. Which of the following would be an appropriate goal?
A. Strive to keep ethnic background from influencing health needs. B. Encourage continuation of ethnic practices in the hospital setting. C. Attempt, in a nonjudgmental way, to change ethnic beliefs. D. Adapt, as necessary, ethnic practices to health needs. |
4. Whenever possible, nursing care should facilitate the integration of ethnic practices into health needs (pp. 73-76).
1. and 3. The ethnic background is part of the individual; it would be very difficult to eliminate the influence of the ethnic background. 2. The ethnic practices need to be evaluated within the context of the health care setting to determine whether they are conflicting. |
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Which of the following statements is true concerning folk remedies?
A. They may be used to reinforce the treatment plan. B. They are incompatible with modern medical regimens. C. They are a leading cause of death in some cultural groups. D. They are not a part of the culture in large, developed countries. |
1. Whenever they are compatible, folk remedies should be used to reinforce the treatment plan. This will assist in establishing a caring environment (p. 69).
2. Depending on the remedy, they may not be incompatible. 3. and 4. These circumstances vary with the remedy. |
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Which of the following terms refers to a shared cultural, social, and linguistic heritage?
A. Beliefs B. Culture C. Ethnicity D. Socialization |
3. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage (p. 56).
1. Beliefs are attitudes that can be shared. 2. Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames the outlook and decisions of a group of people. 4. Socialization is the process by which individuals learn the roles that are expected of them. |
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A mother tells the nurse that her daughter's favorite toy is a large, empty box in which a stove was packaged. She plays house in it with her toddler brother. The nurse should recognize that this is:
A. unsafe play that should be discouraged. B. creative play that should be encouraged. C. suggestive of limited family resources. D. suggestive of limited adult supervision. |
2. This type of play should be encouraged. After children create something new, they can then transfer their new knowledge to other situations (p. 94).
1. As long as the play is supervised, it should be encouraged. 3. No indication of limited resources is evident. 4. No indication of limited adult supervision is evident. |
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According to Piaget, at what stage of development do children typically solve problems through trial and error?
A. Sensorimotor B. Preoperational C. Formal operational D. Concrete operational |
1. During the sensorimotor stage infants and young toddlers develop a sense of cause and effect (p. 89).
2. Relational problem solving is characteristic of the preoperational stage. 3. Adolescents, in the formal operations stage, can test hypotheses. 4. Children in concrete operations solve problems in a tangible systematic fashion. |
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Parents of a 10-year-old child are concerned that their child has been recently showing signs of low self-esteem. Which of the following should the nurse consider when discussing this issue with the parents?
A. Changing self-esteem is difficult after about age 5. B. Self-esteem is the objective judgment of one's worthiness. C. Transitory periods of lowered self-esteem are expected developmentally. D. High self-esteem develops when parents show adequate love for the child. |
3. Self-esteem changes with development. Transient changes are expected and with positive encouragement and support is only temporary (p. 91).
1. Self-esteem is influenced throughout adolescence. 2. One aspect of self-esteem is a subjective judgment of one's worthiness. 4. Self-esteem is based on several components: competence, sense of control, moral worth, and worthiness of love and acceptance. |
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The nurse is discussing toddler development with a parent. Which of the following interventions will foster the achievement of autonomy in the toddler?
A. Help the toddler complete tasks. B. Provide opportunities for the toddler to play with other children. C. Help the toddler learn the difference between right and wrong. D. Encourage the toddler to do things for self when capable of doing them. |
4. Toddlers have an increased ability to control their bodies, themselves, and the environment. Autonomy develops when children complete tasks of which they are capable (pp. 87-88).
1. To successfully achieve autonomy, the toddler needs to have a sense of accomplishment. This does not occur if parents complete tasks for them. 2. Children at this age engage in parallel play. This will not foster autonomy. 3. This concept is too advanced for toddlers and will not contribute to autonomy. |
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Which of the following behaviors is most characteristic of the concrete operations stage of cognitive development?
A. Progression from reflex activity to imitative behavior B. Inability to put oneself in another's place C. Increasingly logical and coherent thought processes D. Ability to think in abstract terms and draw logical conclusions |
3. Such thought processes are characteristic of concrete operations. Children in this stage are able to classify objects (p. 89).
1. This is characteristic of the sensorimotor stage that occurs from birth to 2 years of age. 2. This is characteristic of the preoperational stage (ages 2 to 7). 4. Adolescents, in the formal operations stage, have this ability. |
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Which of the following is an important consideration related to childhood stress?
A. Children should be protected from stress. B. Children do not have coping strategies. C. Parents cannot prepare children for stress. D. Some children are more vulnerable to stress than others. |
4. Children's age, temperament, life situation, and state of health affect their vulnerability, reactions, and ability to handle stress (p. 98).
1. It is not feasible to protect children from all stress. 2. Children can be taught coping strategies. Supportive interpersonal relationships are essential to the psychologic well-being of children. 3. Adults need to recognize signs of stress before they become overwhelming. Providing children with interpersonal security helps them develop coping strategies for dealing with stress. |
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Which of the following statements helps explain the growth and development of children?
A. Development proceeds at a predictable rate. B. Sequence of developmental milestones is predictable. C. Rates of growth are consistent among children. D. At times of rapid growth, there is also acceleration of development. |
2. There is a fixed, precise order to child development (pp. 80-81).
1. There are periods of both accelerated and decelerated growth and development. 3. Each child develops at his or her own rate. 4. Physical growth and development proceed at differing rates. |
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8.
While caring for hospitalized adolescents, the nurse observes that sometimes they are skeptical of their parents' religious beliefs/practices. The nurse should recognize that this is which of the following? A. Normal in spiritual development B. Abnormal in spiritual development C. Related to illness and occurs only at times of crisis D. Related to the inability of parents to explain adequately their beliefs/practices |
1. This describes stage 4 in spiritual development. Adolescents attempt to determine which of their parental standards and beliefs to incorporate into their own (p. 90).
2., 3., and 4. These are normal responses for adolescents. |
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A parent of an 8-month-old infant tells the nurse that the baby cries and screams whenever the infant is left with the grandparents. The nurse's reply should be based on which of the following?
A. Infant is most likely spoiled. B. This is a normal reaction for this age. C. This is an abnormal reaction for this age. D. Grandparents are not responsive to infant. |
2. The infant is experiencing stranger anxiety, which is expected for this age child (pp. 316-317).
1. and 3. This is developmentally appropriate. 4. No data have been shown to support this. |
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According to Erikson, infancy is concerned with acquiring a sense of which of the following?
A. Trust B. Industry C. Initiative D. Separation |
1. The task of infancy is the development of trust (p. 314).
2. Industry vs. inferiority is the developmental task of school-age children. 3. Initiative vs. guilt is the developmental task of preschoolers. 4. Separation occurs during the sensorimotor stage as described by Piaget. |
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At what age would the nurse expect an infant to be able to say "mama" and "dada" with meaning?
A. 4 months B. 6 months C. 10 months D. 14 months |
3. At this age infants say sounds with meaning (pp. 317-323).
1. Consonants are added to infant vocalizations. 2. Babbling resembles one syllable sounds. 4. This is late for the development of sounds with meaning. |
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Michael, age 4 months, is brought to the clinic by his parents for a well-baby checkup. Which of the following should the nurse include at this time concerning injury prevention?
A. Never shake baby powder directly on Michael because it can be aspirated into his lungs. B. Do not permit Michael to chew paint from window ledges because he might absorb too much lead. C. When Michael learns to roll over, you must supervise him whenever he is on a surface from which he might fall. D. Keep doors of appliances closed at all times. |
3. Rolling over from abdomen to back occurs between 4 and 7 months. This is the appropriate anticipatory guidance for this age (p. 347).
1. This is appropriate guidance for a first-month appointment. 2. and 4. This information should be included at the 9-month visit when Michael is beginning to crawl and pull to a stand. |
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The mother of a 3-month-old breast-fed infant asks about giving her baby water since it is summer and very warm. The nurse should recommend that:
A. Fluids in addition to breast milk are not needed. B. Water should be given if infant seems to nurse longer than usual. C. Water once or twice a day will make up for losses due to environmental temperature. D. Clear juices would be better than water to promote adequate fluid intake. |
1. The child will nurse according to needs. Additional fluids are not necessary for the breast-fed baby (p. 329).
2. and 3. Supplemental water should not be given. It may cause water intoxication. 4. Clear juices do not provide sufficient caloric or nutrient intake and may interfere with breast-feeding. |
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The nurse is assessing a 6-month-old infant who smiles, coos, and has a strong head lag. The nurse should recognize which of the following?
A. This is normal. B. Child is probably mentally retarded. C. Developmental/neurologic evaluation is needed. D. Parent needs to work with infant to stop head lag. |
3. The head lag should be almost gone by 4 months of age. This child requires evaluation (pp. 322-324).
1. A six-month-old infant should have social interaction beyond smiling and cooing. 2. Child requires evaluation. 4. Child requires evaluation before interventions can be determined. |
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The parent of 12-month-old Chris says to the nurse, "He pushes the teaspoon right out of my hand when I feed him. I can't let him feed himself; he makes too much mess." The nurse's best response is which of the following?
A. "It's important not to give in to this kind of temper tantrum at this age." B. "Maybe you need to try a different type of spoon, one designed for children." C. "It's important to let him make a mess. Just don't worry about it so much." D. "He is old enough to feed himself. Let's think of ways to make the mess more tolerable." |
4. At 12 months the child should be self-feeding. Since children this age eat primarily finger foods, it is useful to offer parent suggestions for keeping mess to a minimum (p. 331).
1. and 2. The child is developmentally ready for self-feeding. The parent should not force use of the spoon but should substitute finger foods. 3. This response minimizes the parent's concerns about the mess created by self-feeding. |
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The parents of a 9-month-old infant tell the nurse that they are worried about their baby's thumb-sucking. The nurse's reply should be based on which of the following?
A. Pacifier should be substituted for the thumb. B. Thumb-sucking should be discouraged by age 12 months. C. Thumb-sucking should be discouraged when the teeth begin to erupt. D. There is no need to restrain nonnutritive sucking during infancy. |
4. Nonnutritive sucking reaches its peak at about 18 to 20 months of age (pp. 326-327).
1. Evidence is inconclusive regarding whether a pacifier or thumb is better for satisfying sucking needs. 2. Thumb-sucking and use of pacifier should be stopped after 4 years of age. 3. Thumb-sucking and use of pacifier should be stopped after 4 years of age. |
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The parents of a 5-month-old girl complain to the nurse that they are exhausted because she still wakes up as often as every 1 to 2 hours during the night. When she awakens, they change her diaper, and her mother nurses her back to sleep. Which of the following should the nurse suggest to help them deal with this problem?
A. Put her in parents' bed to cuddle. B. Start putting her to bed while still awake. C. Let her cry herself back to sleep. D. Give her a bottle of formula instead of breast-feeding her so often at night. |
2. Parents need to develop bedtime rituals that involve putting child in bed when awake (pp. 332-334).
1. Need to discuss the issue of co-sleeping with parents. Having the infant in bed with them may still interfere with their sleep. 3. If the child is put in bed awake, she will be able to return to sleep more easily if she awakens at night. 4. Providing formula at night will contribute to bottle-mouth caries. |
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Which of the following characteristics best describes the fine motor skills of a 5-month-old infant?
A. Strong grasp reflex B. Neat pincer grasp C. Able to build a tower of two cubes D. Able to grasp object voluntarily |
4. This is appropriate for a 5-month-old infant (pp. 322-324).
1. Characteristic of a 1-month-old infant. 2. Characteristic of an 11-month-old infant. 3. Characteristic of a 15-month-old infant. |
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Which of the following is the most appropriate recommendation for relief of teething pain?
A. Rub gums with aspirin to relieve inflammation. B. Apply hydrogen peroxide to gums to relieve irritation. C. Give child a frozen teething ring to relieve inflammation. D. Have child chew on a warm teething ring to encourage tooth eruption. |
3. Cold reduces inflammation and should be used for relief of teething irritation (p. 328).
1. Should not be done. Can be dangerous if child aspirates aspirin. 2. Hydrogen peroxide would not be effective. 4. Cold, not warmth, reduces inflammation. |
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A 2-year-old child has recently started having temper tantrums during which she holds her breath and sometimes faints. The nurse should:
A. refer child for respiratory evaluation. B. refer child for psychological evaluation. C. explain to parent that this is not harmful. D. explain to parent that child is spoiled. |
3. The rising carbon dioxide levels in the child will automatically restart the breathing process (p. 400).
1. This is not a respiratory issue. 2. Temper tantrums are part of this developmental stage; if they persist, an evaluation may be indicated. 4. No data has been shown to support this. |
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A parent has a 2-year-old in the clinic for a well-child checkup. Which of the following statements by the parent would indicate to the nurse that the parent needs more instruction regarding accident prevention?
A. "We locked all the medicines in the bathroom cabinet." B. "We turned the thermostat down on our hot water heater." C. "We placed gates at the top and bottom of the basement steps." D. "We stopped using the car seat now that my child is older." |
4. A car seat should be used until child weighs 40 pounds, at approximately 4 years of age (p. 408).
1., 2., and 3. These are appropriate actions. |
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For a toddler with sleep problems, the nurse should suggest:
A. using a transitional object. B. varying the bedtime ritual. C. restricting stimulating activities. D. explaining away fears. |
1. A transitional object may help child ease anxiety and facilitate sleep (p. 403).
2. A consistent ritual will facilitate sleep. 3. Child should have stimulating physical activity during the daytime. 4. Verbal explanations are not understood by a child this age. |
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Kara, a hospitalized toddler, clings to a worn, tattered blanket. She screams when anyone tries to take it away. What is the best explanation for her attachment to the blanket?
A. Blanket encourages immature behavior. B. Blanket is an important transitional object. C. She has not mastered the developmental task of individuation-separation. D. She has not bonded adequately with her mother. |
2. The blanket is an important transitional object that provides security when child is separated from parents (p. 395).
1. Transitional objects are important to help toddlers separate. 3. Transitional object is helpful when child is experiencing an increased stress situation, such as hospitalization. 4. This does not reflect bonding behavior. |
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Myelination of the spinal cord is almost complete by 2 years of age. As a result of this, which of the following can gradually be achieved by the toddler?
A. Throwing a ball without falling B. Slowing of gastrointestinal transit time C. Visual acuity of 20/20 D. Control of anal and urethral sphincters |
4. The voluntary control of elimination occurs between 18 and 24 months (pp. 390-391).
1. Casting and throwing a ball occurs at approximately 15 months. 2. Increased capacity is responsible for decreased number of bowel movements each day. 3. Visual acuity is 20/40. |
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Poisoning in toddlers can best be prevented by doing what?
A. Consistently using safety caps B. Storing poisonous substances in a locked cabinet C. Keeping ipecac syrup in the home D. Storing poisonous substances out of reach |
2. This is an appropriate action.
1. Not all poisonous substances have safety caps. 3. Ipecac does not prevent poisoning and is not recommended. 4. Toddlers can climb; therefore, little is out of reach. |
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The nurse is teaching the parent of a 2-year-old child how to care for the child's teeth. Which of the following should be included?
A. Flossing is not recommended at this age. B. Child is old enough to brush teeth effectively. C. Brush teeth with plain water if child does not like toothpaste. D. Toothbrush should be small and have hard, rounded, nylon bristles. |
3. Some children do not like the flavor of toothpaste or the foam; water alone can be used (p. 404).
1. Flossing should be done after brushing. 2. Two-year-olds cannot effectively brush their own teeth; parental assistance is necessary. 4. Soft, multitufted, bristled toothbrushes are recommended. |
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The nurse notices that a toddler is more cooperative when taking medicine from a small cup rather than from a large cup. This is an example of which of the following characteristics of preoperational thought?
A. Egocentrism B. Irreversibility C. Inability to conserve D. Transductive reasoning |
3. The smaller cup makes it look like less medicine (p. 394).
1. The inability to see situations from other perspectives does not facilitate medication administration. 2. The inability to reverse actions physically initiated does not facilitate medication administration. 4. Focusing on particulars does not explain the cooperation with the smaller medication cup. |
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When explaining the proper restraint of toddlers in motor vehicles, the nurse should include:
A. safety belts should be worn snugly over abdomen. B. place safety seat in front passenger seat if there is an airbag. C. use lap/shoulder belts when child is over 3 years of age. D. use a tether strap if recommended by safety seat manufacturer. |
4. Manufacturers' recommendations should always be followed when installing car seats (p. 411).
1. Safety belts can cause injuries if placed over abdomen. 2. Car seat should be in rear. Airbag can cause injury. 3. Three-year-olds should be restrained in car seats. |
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Which of the following characterizes the development of a 2-year-old child?
A. Engages in parallel play B. Fully dresses self with supervision C. Has a vocabulary of at least 500 words D. Has attained one third of the adult height |
1. Two-year-olds typically play alongside each other (p. 396).
2. Child still needs help with clothing at 2 years of age. 3. A vocabulary of 300 words is expected at this age. 4. Child typically has grown to one-half of adult height. |
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Which of the following should the nurse recommend to help a toddler cope with the birth of a new sibling?
A. Give toddler a doll on which he or she can imitate parenting. B. Discourage toddler from helping with care of new sibling. C. Prepare toddler for upcoming changes about 1 to 2 weeks before birth of sibling. D. Explain to toddler that a new playmate will soon come home. |
1. The toddler can participate in the activity of caring for a new family member (pp. 397-398).
2. The child should be encouraged to participate in accordance with his or her abilities. 3. Preparation should begin as soon as changes in the mother's physical appearance and the home setting occur. 4. This will establish unrealistic expectations. |
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Which of the following statements about bottle-mouth caries is correct?
A. Syndrome is distinguished by protruding upper front teeth, resulting from sucking on a hard nipple. B. Giving a bottle of milk or juice at nap time or bedtime predisposes the child to this syndrome. C. Syndrome can be prevented by breast-feeding. D. Giving the child juice in the bottle instead of milk at bedtime prevents this syndrome. |
2. Sweet liquids pooling in mouth during sleep cause dental caries (p. 405).
1. This may result from pacifier use or thumb sucking. 3. Frequent breast-feeding before sleep can also cause bottle-mouth caries. 4. Juice in bottles before sleep contributes to bottle-mouth caries. |
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Which one of the following statements is most characteristic of the motor skills of a 24-month-old child?
A. Toddler walks alone but falls easily. B. Toddler's activities begin to produce purposeful results. C. Toddler is able to grasp small objects but cannot release them at will. D. Toddler's motor skills are fully developed but occur in isolation from the environment. |
2. Gross and fine motor mastery occur with other activities (p. 391).
1. Child is able to walk up and down stairs at this age. 3. This is a task of infancy. 4. Interaction with the environment is essential at this age. |
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Which statement characterizes toddlers eating behavior?
A. They have increased appetites. B. They have few food preferences. C. Their table manners are predictable. D. They become fussy eaters. |
4. Toddlers have physiologic anorexia that contributes to fussy eating (pp. 401-402).
1. They have a decrease in appetite. 2. They have strong taste preferences. 3. Use of finger foods contributes to unpredictable table manners. |
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A 4½-year-old boy has been having increasingly more frequent angry outbursts in preschool. He is very aggressive toward the other children and the teachers. This behavior has been a problem for approximately 8 to 10 weeks. His parent asks the nurse for advice. Which of the following is the most appropriate intervention?
A. Explain that this is normal in preschoolers, especially boys. B. Refer the child for professional help. C. Talk to the preschool teacher to obtain validation for behavior parent reports. D. Encourage the parent to try more consistent and firm discipline. |
2. This is not expected behavior; the child should be referred to a competent professional to deal with his aggression (p. 427).
1. This is not normal behavior. 3. The validation will be helpful for the referral, but the referral is the priority action. 4. This may be recommended by the professional. |
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According to Erikson, the primary psychosocial task of the preschool period is developing a sense of what?
A. Identity B. Intimacy C. Initiative D. Industry |
3. Preschoolers focus on developing initiative. The stage is known as initiative vs. guilt (pp. 417-418).
1. This is the stage associated with adolescence. 2. This an adult stage. 4. This is an adult stage. |
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Ashley, age 4½, is afraid of dogs. The nurse should recommend which of the following to her parents to help her with this fear?
A. Keep her away from dogs. B. Buy her a stuffed dog toy. C. Force her to touch a dog briefly. D. Let her watch other children play with a dog. |
4. The parents should actively seek ways to deal with fear. By observing other children at play with dogs, the child can learn to adapt (p. 426).
1. and 2. These actions avoid the object of fear rather than approaching it and finding solutions. 3. Forcing the child to interact with the dog may increase the level of fear. |
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Because of the preschooler's egocentric thought, the best approach for effective communication is through:
A. speech. B. play. C. drawing. D. actions. |
2. Play is the child's way to learn to understand and adjust to situations (p. 418).
1. Language is not specific for children. 3. Drawing is not developed at this age. 4. Actions are not effective for communication. |
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By preschool age the child's body image has developed to include:
A. a well-defined body boundary. B. knowledge about his or her internal anatomy. C. fear of intrusive procedures. D. anxiety and fear of separation. |
3. Preschoolers fear that their insides will come out with intrusive procedures (p. 419).
1. They have poorly defined body images. 2. Preschoolers have little or no knowledge of their internal anatomy. 4. Preschoolers are able to separate. |
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During a well-child visit, the father of a 4-year-old boy tells the nurse that he is not sure if his son is ready for kindergarten. His birthday is close to the cut-off date and he has not attended preschool. Which of the following is the nurse's best recommendation?
A. Start kindergarten B. Perform developmental screening C. Observe a kindergarten class D. Postpone kindergarten and go to preschool |
2. A developmental screening will provide the necessary information to help the family determine readiness (p. 422).
1. This does not address the father's concern about readiness. 3. This will provide information about kindergarten but not whether the child is ready. 4. If the child is ready for kindergarten, preschool may lead to boredom. |
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Kimberly, age 4½, sometimes wakes her parents up at night screaming, thrashing, sweating, and apparently frightened. Yet she is not aware of her parents' presence when they check on her. She lays down and sleeps without any parental intervention. This is most likely which of the following?
A. Nightmare B. Sleep terror C. Seizure activity D. Sleep apnea |
2. In sleep terrors the child is only partially aroused; therefore she does not remember her parent's presence (p. 429).
1. A nightmare is a frightening dream followed by full awakening. 3. This does not resemble seizure activity. 4. Sleep apnea is a cessation of breathing during sleep. |
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The nurse is giving anticipatory guidance to the parent of a 5-year-old. Which of the following is the most appropriate to include?
A. Prepare parent for increased aggression. B. Encourage parent to offer child choices. C. Inform parent to expect a more tranquil period at this age. D. Advise parents that this is the age when stuttering may develop. |
3. The end of preschool/beginning of school age is a more tranquil period (p. 430).
1. This is indicative of age 4 anticipatory guidance. 2. and 4. These actions are indicative of age 3 anticipatory guidance. |
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The nurse would expect that most children would be using sentences of six to eight words by what age?
A. 18 months B. 24 months C. 3 years D. 5 years |
4. Children can make sentences of 6 to 8 words at this age (p. 423).
1. This age child has a vocabulary of only 10 words. 2. A child this age uses 2- to 3-word phrases. 3. A child this age uses 3- to 4-word sentences. |
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The parents of a 4½-year-old girl are worried because she has an imaginary playmate. The nurse should respond based on knowledge that:
A. a psychosocial evaluation is indicated. B. an evaluation of possible parent-child conflict is indicated. C. having imaginary playmates is normal and useful at this age. D. having imaginary playmates is abnormal after about age 2 years. |
3. Imaginary playmates are a part of normal development at this age (p. 422).
1. and 2. Since an imaginary playmate is part of normal development, an evaluation is not necessary. 4. The peak incidence of imaginary playmates occurs at 2.5 to 3 years of age. These "playmates" usually are not present once school starts. |
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When preparing parents to teach their children about human sexuality, the nurse should emphasize which of the following?
A. Parents' words may have a greater influence on the child's understanding than the parent's actions. B. Parents should determine exactly what the child wants to know before answering a question about sex. C. Parents should avoid using correct anatomic terms because they are confusing to the preschooler. D. Parents should allow children to satisfy their sexual curiosity by playing doctor. |
2. It is important that the parents answer the question that the child is asking (p. 423).
1. The actions may have a greater influence because language is not fully developed. 3. Using correct terminology lays the foundation for later discussion. 4. Parents should encourage the asking of questions to resolve curiosity without undue investigation on the child's part. |
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Which of the following is descriptive of the nutritional requirements of preschool children?
A. Quality of the food consumed is more important than the quantity. B. Nutritional requirements for preschoolers are very different from requirements for toddlers. C. Requirement for calories per unit of body weight increases slightly during the preschool period. D. Average daily intake of preschoolers should be about 3000 calories. |
1. It is essential that the child eat a balanced diet with essential nutrients (p. 429).
2. Requirements are similar. 3. Caloric requirement decreases slightly. 4. Average intake is about 1800 calories each day. |
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A parent phones the nurse and says that her child just knocked out a permanent tooth. The nurse's instructions to the parent should include which of the following?
A. Rinse tooth in hot water. B. Hold tooth by crown and not by root area. C. Take child and tooth to a dentist within 48 hours. D. Take child to hospital emergency room if mouth is bleeding. |
2. The root area should not be touched.
1. Only if dirty, should the tooth be rinsed with running water. 3. Reimplantation should occur within 30 minutes by child, parent, or nurse and stabilized by a dentist as soon as possible. 4. The child needs to be seen by a competent dentist as soon as possible. |
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A parent tells the nurse, "I am worried about my 13-year-old son. He hasn't started puberty, and my daughter did when she was 11 years of age." The nurse should explain to this parent that this is which of the following?
A. Unusual and requires further evaluation of the son B. Unusual because the onset of pubescence is usually the same in siblings C. Normal because the onset of pubescence is usually earlier in girls than it is in boys D. Abnormal because the onset of pubescence is usually earlier in boys than it is in girls |
3. Girls begin puberty an average of approximately 2 years before boys (p. 474).
1. and 4. The average age of onset for puberty in boys is 12 years old. 2. Age of pubescence is gender related. |
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Nursing interventions to promote health during middle childhood include which of the following?
A. Stress the need for increased calorie intake to meet increased demands. B. Instruct parents to defer questions about sex until the child reaches adolescence. C. Educate child and parents to the need for good dental hygiene, because these are the years in which permanent teeth erupt. D. Advise parents that the child will need decreasing amounts of rest toward the end of this period. |
3. Because the permanent teeth are present, it is important for the child to learn how to care for these teeth (pp. 486-488).
1. Caloric needs are diminished; however, a balanced diet is important to prepare for the adolescent growth spurt. 2. Parents should approach sex education with a life span approach and respond to a child's questions with an answer appropriate to the childs age. 4. School-age children often need to be reminded to go to sleep. |
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The parents of 9-year-old twin children tell the nurse, "They have filled up their bedroom with collections of rocks, shells, stamps, and cars." The nurse should recognize that this is which of the following?
A. Indicative of giftedness B. Indicative of typical "twin" behavior C. Characteristic of cognitive development at this age D. Characteristic of psychosocial development at this age |
3. Classification skills are developed during the school-age years. This age group enjoys sorting objects according to shared characteristics (p. 475).
1. This is characteristic of the age group, not giftedness. 2. This is characteristic of the age group, not their twin status. 4. Psychosocial development at this age is focused on accomplishment. |
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The parents of an 8-year-old girl tell the nurse that their daughter wants to join a soccer team. The nurse's suggestions regarding participation in sports at this age should include which of the following?
A. Organized sports, such as soccer, are not appropriate at this age. B. Competition is detrimental to the establishment of a positive self-image. C. Sports participation is encouraged if the sport is appropriate to the child's abilities. D. Girls should compete only against girls because at this age boys are larger and have more muscle mass. |
3. The parent should help the child select a sport that is suitable to her capabilities and interests (p. 485).
1. Organized sports can provide safe, appropriate activities with supportive parents and coaches. A sport should be selected that meets the child's capabilities and interests. 2. School-age children enjoy competition. Parents and coaches need to recognize child's abilities and teach proper techniques so the child can compete safely. 4. These changes occur at puberty. Prior to that boys and girls can compete on the same teams. |
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The school nurse is asked to speak with the parents of a 10-year-old boy who has been bullying other children. The nurse's response should be based on knowledge that:
A. Bullying at this age is considered normal. B. Children who bully others usually join gangs. C. Children who bully others usually have low self-esteem. D. Bullies often have difficulties developing and maintaining relationships. |
Correct Answer: D
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The school nurse is discussing dental health with some children in first grade. Which of the following should be included?
A. Teach how to floss teeth properly. B. Recommend toothbrush with hard nylon bristles. C. Emphasize importance of brushing before bedtime. D. Recommend nonfluoridated toothpaste approved by the American Dental Association. |
3. Children should be taught to brush their teeth after meals, snacks, and before bedtime (pp. 486-487).
1. Parents should help with flossing until children develop the dexterity required, which occurs at about the time of third grade. 2. A toothbrush with soft nylon bristles is recommended. 4. The American Dental Association recommends fluoridated toothpaste for this age group. |
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Which of the following is an important consideration in preventing injuries during middle childhood?
A. Peer pressure is not strong enough to affect risk-taking behavior. B. Most injuries occur in or near school or home. C. Injuries from burns are the highest at this age because of fascination with fire. D. Lack of muscular coordination and control results in an increased incidence of injuries. |
2. This is where most injuries occur (p. 489).
1. Peer pressure is significant in this age group. 3. Automobile accidents account for the majority of severe accidents, either as a pedestrian or passenger. 4. School-age children have more refined muscle development, which results in an overall decrease in the number of accidents. |
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Which of the following is characteristic of the psychosocial development of school-age children?
A. A developing sense of initiative is very important. B. Peer approval is not yet a motivating power. C. Motivation comes from extrinsic rather than intrinsic sources. D. Feelings of inferiority or lack of worth can be derived from children themselves or from the environment. |
4. This age child is eager to develop skills and participate in activities. All children are not able to do all tasks well, and the child must be prepared to accept some feeling of inferiority (pp. 474-475).
1. This is characteristic of preschoolers. 2. Peer group formation is one of the major characteristics of this age group. 3. School-age children gain satisfaction from independent behaviors. |
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Which of the following is descriptive of the social development of school-age children?
A. Identification with peers is minimal. B. Children frequently have best friends. C. Boys and girls play equally well with children of either gender. D. Peer approval is not yet an influence toward conformity. |
2. Same-sex peers form relationships that encourage sharing of secrets and jokes and coming to each other's aid (p. 477).
1. Identification with peer group is an important factor toward gaining independence from families. 3. During the school-age years there are more gender-specific groups. 4. Conforming to the rules is an essential part of group membership. |
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Which of the following should the nurse include when giving parents guidelines about helping their children in school? A. Help children as much as possible with their homework. B. Punish children who fail to perform adequately. C. Communicate with teachers if there appears to be a problem. D. Accept responsibility for children's successes and failures. |
3. Parents should communicate with teachers if there is a problem and not wait for a scheduled conference (p. 483).
1. Children need to do their own homework. This cultivates responsibility. 2. Discipline should be used to help children control behaviors. School-age children can use reasoning skills. 4. School-age children need to develop responsibility. This helps with keeping promises and meeting deadlines, thereby laying successful foundations for adulthood. |
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A 12-year-old child being seen in the clinic has not received the hepatitis B (HBV) vaccine. The nurse should recommend that:
A. only one dose of HBV will be needed sometime during adolescence. B. one dose of HBV is needed at age 14. C. the three-dose series of HBV should be started. D. the three-dose series of HBV should be started at age 16 or sooner if the adolescent becomes sexually active. |
3. Adolescents should be vaccinated against hepatitis B at this age if not done previously (pp. 506, 335).
1. and 2. Three doses are necessary to achieve immunity. 4. The recommendation is that the hepatitis B vaccine series be started at birth. The AAP recommends vaccination by age 13. |
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A 16-year-old adolescent male tells the school nurse that he is gay. The nurse's response should be based on knowledge that:
A. he is too young to have had enough sexual activity to determine this. B. it is important to provide a nonthreatening environment in which he can discuss this. C. the nurse should feel open to discussing his or her own beliefs about homosexuality. D. homosexual adolescents do not have concerns that differ from heterosexual adolescents. |
2. The nurse needs to be open and nonjudgmental in interactions with adolescents. This will provide a safe environment in which to provide appropriate health care (p. 503).
1. Adolescence is when sexual identity develops. 3. The nurse's own beliefs should not bias the interaction with this student. 4. Homosexual adolescents face very different challenges as they grow up because of society's response to homosexuality. |
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The parents of 9-year-old twin children tell the nurse, "They have filled up their bedroom with collections of rocks, shells, stamps, and cars." The nurse should recognize that this is which of the following?
A. Indicative of giftedness B. Indicative of typical "twin" behavior C. Characteristic of cognitive development at this age D. Characteristic of psychosocial development at this age |
3. Classification skills are developed during the school-age years. This age group enjoys sorting objects according to shared characteristics (p. 475).
1. This is characteristic of the age group, not giftedness. 2. This is characteristic of the age group, not their twin status. 4. Psychosocial development at this age is focused on accomplishment. |
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The parents of an 8-year-old girl tell the nurse that their daughter wants to join a soccer team. The nurse's suggestions regarding participation in sports at this age should include which of the following?
A. Organized sports, such as soccer, are not appropriate at this age. B. Competition is detrimental to the establishment of a positive self-image. C. Sports participation is encouraged if the sport is appropriate to the child's abilities. D. Girls should compete only against girls because at this age boys are larger and have more muscle mass. |
3. The parent should help the child select a sport that is suitable to her capabilities and interests (p. 485).
1. Organized sports can provide safe, appropriate activities with supportive parents and coaches. A sport should be selected that meets the child's capabilities and interests. 2. School-age children enjoy competition. Parents and coaches need to recognize child's abilities and teach proper techniques so the child can compete safely. 4. These changes occur at puberty. Prior to that boys and girls can compete on the same teams. |
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The school nurse is asked to speak with the parents of a 10-year-old boy who has been bullying other children. The nurse's response should be based on knowledge that:
A. Bullying at this age is considered normal. B. Children who bully others usually join gangs. C. Children who bully others usually have low self-esteem. D. Bullies often have difficulties developing and maintaining relationships. |
Correct Answer: D
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The school nurse is discussing dental health with some children in first grade. Which of the following should be included?
A. Teach how to floss teeth properly. B. Recommend toothbrush with hard nylon bristles. C. Emphasize importance of brushing before bedtime. D. Recommend nonfluoridated toothpaste approved by the American Dental Association. |
3. Children should be taught to brush their teeth after meals, snacks, and before bedtime (pp. 486-487).
1. Parents should help with flossing until children develop the dexterity required, which occurs at about the time of third grade. 2. A toothbrush with soft nylon bristles is recommended. 4. The American Dental Association recommends fluoridated toothpaste for this age group. |
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Which of the following is an important consideration in preventing injuries during middle childhood?
A. Peer pressure is not strong enough to affect risk-taking behavior. B. Most injuries occur in or near school or home. C. Injuries from burns are the highest at this age because of fascination with fire. D. Lack of muscular coordination and control results in an increased incidence of injuries. |
2. This is where most injuries occur (p. 489).
1. Peer pressure is significant in this age group. 3. Automobile accidents account for the majority of severe accidents, either as a pedestrian or passenger. 4. School-age children have more refined muscle development, which results in an overall decrease in the number of accidents. |
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Which of the following is characteristic of the psychosocial development of school-age children?
A. A developing sense of initiative is very important. B. Peer approval is not yet a motivating power. C. Motivation comes from extrinsic rather than intrinsic sources. D. Feelings of inferiority or lack of worth can be derived from children themselves or from the environment. |
4. This age child is eager to develop skills and participate in activities. All children are not able to do all tasks well, and the child must be prepared to accept some feeling of inferiority (pp. 474-475).
1. This is characteristic of preschoolers. 2. Peer group formation is one of the major characteristics of this age group. 3. School-age children gain satisfaction from independent behaviors. |
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Which of the following is descriptive of the social development of school-age children?
A. Identification with peers is minimal. B. Children frequently have best friends. C. Boys and girls play equally well with children of either gender. D. Peer approval is not yet an influence toward conformity. |
2. Same-sex peers form relationships that encourage sharing of secrets and jokes and coming to each other's aid (p. 477).
1. Identification with peer group is an important factor toward gaining independence from families. 3. During the school-age years there are more gender-specific groups. 4. Conforming to the rules is an essential part of group membership. |
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Which of the following should the nurse include when giving parents guidelines about helping their children in school? A. Help children as much as possible with their homework. B. Punish children who fail to perform adequately. C. Communicate with teachers if there appears to be a problem. D. Accept responsibility for children's successes and failures. |
3. Parents should communicate with teachers if there is a problem and not wait for a scheduled conference (p. 483).
1. Children need to do their own homework. This cultivates responsibility. 2. Discipline should be used to help children control behaviors. School-age children can use reasoning skills. 4. School-age children need to develop responsibility. This helps with keeping promises and meeting deadlines, thereby laying successful foundations for adulthood. |
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A 12-year-old child being seen in the clinic has not received the hepatitis B (HBV) vaccine. The nurse should recommend that:
A. only one dose of HBV will be needed sometime during adolescence. B. one dose of HBV is needed at age 14. C. the three-dose series of HBV should be started. D. the three-dose series of HBV should be started at age 16 or sooner if the adolescent becomes sexually active. |
3. Adolescents should be vaccinated against hepatitis B at this age if not done previously (pp. 506, 335).
1. and 2. Three doses are necessary to achieve immunity. 4. The recommendation is that the hepatitis B vaccine series be started at birth. The AAP recommends vaccination by age 13. |
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A 16-year-old adolescent male tells the school nurse that he is gay. The nurse's response should be based on knowledge that:
A. he is too young to have had enough sexual activity to determine this. B. it is important to provide a nonthreatening environment in which he can discuss this. C. the nurse should feel open to discussing his or her own beliefs about homosexuality. D. homosexual adolescents do not have concerns that differ from heterosexual adolescents. |
2. The nurse needs to be open and nonjudgmental in interactions with adolescents. This will provide a safe environment in which to provide appropriate health care (p. 503).
1. Adolescence is when sexual identity develops. 3. The nurse's own beliefs should not bias the interaction with this student. 4. Homosexual adolescents face very different challenges as they grow up because of society's response to homosexuality. |
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Girls experience an increase in weight and fat deposition during puberty. Nursing considerations related to this include which of the following?
A. Give reassurance that these changes are normal. B. Suggest dietary measures to control weight gain. C. Recommend increased exercise to control weight gain. D. Encourage low-fat diet to prevent fat deposition. |
1. A certain amount of fat is increased along with lean body mass to fill the characteristic contours of the child's gender. A healthy balance must be achieved between expected healthy weight gain and obesity (p. 498).
2. and 3. Such advice would not be given unless weight gain was excessive; eating disorders can develop in this group. 4. Some fat deposition is essential for normal hormonal regulation. Menarche is delayed in girls with body fat contents that are too low. |
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How does the onset of the pubertal growth spurt compare in girls and boys? A. In girls, it occurs about 1 year before it appears in boys. B. In girls, it occurs about 3 years before it appears in boys. C. In boys, it occurs about 1 year before it appears in girls. D. It is about the same in both boys and girls. |
1. Average age of onset is 9.5 years for girls and 10.5 for boys (p. 495)
2. Although this may be true on an individual basis, the average difference is 1 year. 3. and 4. Usually girls begin their pubertal growth spurt earlier than boys. |
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In boys, the initial indication of puberty is which of the following?
A. Testicular enlargement B. Voice changes C. Growth of dark pubic hair D. Increased size of penis |
1. Testicular enlargement is the first change that signals puberty in boys; it usually occurs between the ages of 9.5 and 14 years during Tanner stage 2 (p. 494).
2. Voice change occurs between Tanner stages 3 and 4. 3. Fine pubic hair may occur at the base of the penis; darker hair occurs during Tanner stage 3. 4. Penis enlarges during Tanner stage 3. |
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The nurse observes that 13-year-old Mike has gynecomastia (breast enlargement). The nurse should explain to Mike that this is a/an:
A. sign of too much body fat. B. sign of hormonal imbalance. C. normal occurrence during puberty. D. indication of precocious puberty. |
3. Gynecomastia is common during mid puberty in about one-third of boys. For most, the breast enlargement disappears within 2 years (p. 495).
1. Although this may be true in overweight children, in children of normal body weight it is a normal occurrence. 2. If the gynecomastia persists beyond the 2 years, then a hormonal cause may need to be investigated. 4. Precocious puberty is the early onset of puberty, before age 9 in boys. |
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The school nurse is teaching a class on injury prevention. Which of the following should be included when discussing firearms?
A. Adolescents are too young to use a gun properly for hunting. B. Gun carrying among adolescents is on the rise, primarily among inner-city youth. C. Nonpowder guns (air rifles, BB guns) are a relatively safe alternative to powder guns. D. Adolescence is the peak age for being a victim and/or offender in the case of injury involving a firearm. |
4. Gun carrying among adolescents is on the rise. The increase in gun availability is linked to increased gun deaths among children (p. 513).
1. Adolescents can be taught to safely use guns for hunting, but they must be stored properly and used only with supervision. 2. Gun carrying is on the rise among adolescents and is not limited to just the stereotypic inner-city youth population. 3. These types of nonpowder guns cause almost as many injuries as powder guns. |
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When discussing sex and sexual activities with adolescents, the nurse should do which of the following?
A. Present normal body functions in a straight-forward manner. B. Refer the adolescents to their parents for sexual information. C. Use scientific terminology to convey content. D. Defer giving information about pregnancy unless the adolescents are sexually active. |
1. The nurse should provide accurate and complete information that is presented using correct terminology (p. 511).
2. Parents are important influences regarding the morals and values surrounding sexual activities; nurses should provide the adolescent with accurate, complete information about the normal physical aspects of sex. 3. The adolescent may not understand the scientific names. 4. Adolescents should have information before they become sexually active. |
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Which of the following is an important consideration for the school nurse planning a class on injury prevention for adolescents?
A. Adolescents generally are not risk takers. B. Adolescents can anticipate the long-term consequences of serious injuries. C. During adolescence, a need exists for discharging energy, often at the expense of logical thinking. D. During adolescence, participation in sports should be limited to prevent permanent injuries. |
3. The physical, sensory, and psychomotor development of adolescents provides a sense of strength and confidence. There is also an increase in energy coupled with risk taking that puts them at risk (p. 511).
1. Adolescents are risk takers because of their feelings of indestructibility. 2. The feelings of indestructibility that are common in adolescence interfere with understanding the consequences. 4. Sports can be a useful way for adolescents to discharge energy. Care must be taken to avoid overuse injuries. |
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Which of the following is most descriptive of the spiritual development of the older adolescent?
A. Beliefs become more abstract. B. Rituals and practices become increasingly important. C. Strict observance of religious customs is common. D. Emphasis is placed on external manifestations, such as whether a person goes to church. |
1. Due to their abstract thinking abilities, adolescents are able to interpret analogies and symbols (p. 500).
2. and 3. These become less important as the adolescent questions values and ideals of families. 4. Adolescents question external manifestations when not supported by adherence to supportive behaviors. |
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The nurse observes a play group of 2-year-old children. The nurse would expect to see:
1. four children playing dodgeball. 2. three children playing tag. 3. two children side by side in the sandbox building sand castles. 4. one child digging a hole and another child blowing bubbles. |
Correct Answer: 3
RATIONALES: Two-year-olds exhibit parallel play; that is, they engage in similar activity, side by side. Playing dodgeball and tag are examples of interactive play, common to school-age children. A 2-year-old wouldn't blow bubbles. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension |
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When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, doing this helps the child achieve :
1. trust. 2. autonomy. 3. industry. 4. initiative. |
Correct Answer 2
RATIONALES: According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and doubt. An infant is at the stage of trust versus mistrust; a school-age child, industry versus inferiority; and a preschooler, initiative versus guilt. |
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A 10-year-old child visits the pediatrician's office for his annual physical examination. When the nurse asks how he's doing, he becomes quiet and states that his grandmother died last week. Which statements by the client show that he understands the concept of death?
1. "Once you die you never come back" 2. "All people must die." 3. "My grandmother's death has been hard to understand." 4. "My grandmother died because she was sick and nothing could make her better." 5. "My grandmother is dead, but she'll come back." 6. "My grandmother died because someone in the family did something bad. |
Correct Answer 1,3,4
RATIONALES: By age 10, most children know that death is irreversible and final. However, a child may still have difficulty understanding the specific death of a loved one. School-age children should be able to identify cause and effect relationships, such as when a terminal illness causes someone to die. Adolescents, not school-age children, understand that death is a universal process. Preschoolers see death as temporary and may think of death as a punishment. |
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The nurse is teaching the parents of a 6-month-old infant about usual growth and development. Which statements are true regarding infant development?
1. A 6-month-old infant has difficulty holding objects. 2. A 6-month-old infant can usually roll from prone to supine and supine to prone positions. 3. A teething ring is appropriate for a 6-month-old infant. 4. Stranger anxiety usually peaks at age 12 to 18 months. 5. Head lag is commonly noted in infants at age 6 months. 6. Lack of visual coordination usually resolves by age 6 months. |
Correct Answer 2,3,6
RATIONALES: Gross motor skills of the 6-month-old infant include rolling from front to back and back to front. Teething usually begins around age 6 months; therefore, a teething ring is appropriate. Visual coordination is usually resolved by age 6 months. At age 6 months, fine motor skills include purposeful grasps. Stranger anxiety normally peaks at 8 months of age. The 6-month-old infant also should have good head control and no longer display head lag when pulled up to a sitting position. |
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A mother brings her 8-month-old son to the pediatrician's office. When the nurse approaches to measure the child's vital signs, he clings to his mother tightly and starts to cry. The mother says, "He used to smile at everyone. I don't know why he's acting this way." Which response by the nurse would help the mother understand her child's behavior?
1. "Your baby's behavior indicates stranger anxiety, which is common at his age." 2. "Children who behave that way are developing shy personalities." 3. "Children at his age begin to fear pain." 4. "Your baby's having a temper tantrum, which is common at his age." |
Correct Answer 1
RATIONALES: Stranger anxiety, common in infants ages 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-age 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. |
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The nurse expects an infant to sit up without support at which age?
1. 4 months 2. 6 months 3. 8 months 4. 10 months |
Correct 3
RATIONALES: Most infants can sit up without support by age 8 months. At age 4 months, the infant can lift the head off the mattress up to a 90-degree angle. Between ages 6 and 7 months, the infant can sit while leaning forward on the hands. At age 10 months, the infant typically can move from a prone to a sitting position and pull himself up to a standing position. |
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The mother of a 12-month-old child expresses concern about the effects of her child's frequent thumb-sucking. After the nurse provides instruction on this topic, which response by the mother indicates that teaching has been effective?
1. "Thumb-sucking should be discouraged at age 12 months." 2. "I'll give my baby a pacifier instead." 3. "Sucking is important to the baby." 4. "I'll wrap the baby's thumb in a bandage." |
Correct 3
RATIONALES: Sucking is the infant's chief pleasure. 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. A young child is likely to chew on a bandage, possibly leading to airway obstruction. |
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For an 8-month-old infant, which toy promotes cognitive development?
1. Finger paint 2. Jack-in-the-box 3. A small rubber ball 4. A play gym strung across the crib |
Correct 2
RATIONALES: According to Piaget's theory of cognitive development, an 8-month-old child will look for an object once it disappears from sight to develop the cognitive skill of object permanence. Finger paint and small balls are potentially dangerous because infants frequently put their fingers or objects in their mouths. Anything strung across a crib, such as a play gym, is a safety hazard — especially to a child who may use it to pull up to a standing position. |
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For children from infancy through the preschool years, what is the major stressor posed by hospitalization?
1. Separation from the family 2. Fear of bodily injury 3. Loss of control 4. Fear of pain |
Correct 1
RATIONALES: For infants through preschoolers, separation from the family is the major stressor posed by hospitalization. To minimize the effects of separation, the nurse may suggest that a family member stay with the child as much as possible. Reducing this stressor may help a young child withstand other stressors of hospitalization, such as fear of bodily injury, loss of control, and fear of pain. |
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A healthy 2-month-old infant is being seen in the local clinic for a well-child checkup and initial immunizations. The nurse should anticipate administering which immunizations?
1. DTaP (diphtheria, tetanus, and acellular pertussis) 2. MMR (measles, mumps, and rubella) 3. OPV (oral polio vaccine) 4. HBV (hepatitis B vaccine) 5. Varicella (chickenpox) vaccine 6. HIB (Haemophilus influenzae type b vaccine) |
Correct 1,4,6
RATIONALES: At age 2 months, the American Academy of Pediatrics recommends the administration of DTaP, IPV (inactivated polio vaccine), HBV, HIB, and pneumococcal conjugate vaccine. The MMR immunization should be administered at 12 to 15 months. The IPV — not the OPV — is currently used to minimize spread of polio. Infants may receive the varicella vaccine any time after the child's 1st birthday. |
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The nurse is conducting an examination of a 6-month-old baby. During the examination, the nurse should be able to elicit which reflex?
1. Babinski's 2. Startle 3. Moro's 4. Dance |
Correct 1
RATIONALES: Babinski's reflex may be present the entire first year of life. The startle reflex disappears around 4 months of age; the Moro reflex, by 3 or 4 months of age; and the dance reflex, after the 3rd or 4th week. |
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A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate?
1. "The baby is gaining weight and doing well. There is no need for solid food yet." 2. "Things have changed a lot since your children were born." 3. "We've found that babies can't digest solid food properly until they're 3 or 4 months old." 4. "We've learned that introducing solid food early leads to eating disorders later in life. |
Correct 3
RATIONALES: Infants younger than 3 or 4 months lack the enzymes needed to digest complex carbohydrates. Option 1 doesn't address the grandmother's question directly. Option 2 is a cliché that may block further communication with the grandmother. Option 4 is incorrect because no evidence suggests that introducing solid food early causes eating disorders. |
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The nurse expects to observe an infant transferring an object from one hand to another at which age?
1. 4 months 2. 6 months 3. 9 months 4. 12 months |
2
RATIONALES: An infant typically transfers objects from one hand to another between ages 6 and 7 months. The infant can grasp a rattle in the hands at age 4 months, bang objects together between ages 9 and 10 months, and place objects in a container by age 12 months. |
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A 2-month-old baby hasn't received any immunizations. Which immunizations should the nurse prepare to administer?
1. Measles, mumps, rubella (MMR); diphtheria, tetanus, pertussis (DTP); and hepatitis B (HepB) 2. Polio (IPV), DTP, MMR 3. Varicella, Haemophilus influenzae type b (HIB), IPV, and DTP 4. HIB, DTP, HepB; and IPV |
4
RATIONALES: The current immunizations recommended for a 2-month-old who hasn't received any immunizations are HIB, DTP, HepB, and IPV. The first immunizations for MMR and varicella are recommended when a child is 12 months old. |
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The nurse is teaching the mother of a newborn. The nurse should instruct the mother to introduce her infant to solid foods at what age?
1. 2 months 2. 4 months 3. 6 months 4. 8 months |
3
RATIONALES: Solid foods are typically introduced around age 6 months. They aren't recommended at an earlier age because of the protrusion and sucking reflexes and the immaturity of the infant's GI tract and immune system. By age 8 months, the infant usually has been introduced to iron-fortified infant cereal and vegetables and will begin to try fruits. |
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The nurse notes that an infant develops arm movement before fine-motor finger skills and interprets this as an example of which pattern of development?
1. Cephalocaudal 2. Proximodistal 3. Differentiation 4. Mass-to-specific |
2
RATIONALES: Proximodistal development progresses from the center of the body to the extremities, such as from the arm to the fingers. Cephalocaudal development occurs along the body's long axis; for example, the infant develops control over the head, mouth, and eye movements before the upper body, torso, and legs. Mass-to-specific development, sometimes called differentiation, occurs as the child masters simple operations before complex functions and moves from broad, general patterns of behavior to more refined ones. |
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A nurse is conducting an infant nutrition class for parents. Which foods should the nurse tell parents it's okay to introduce during the first year of life?
1. Sliced beef 2. Pureed fruits 3. Whole milk 4. Rice cereal 5. Strained vegetables 6. Fruit juice |
2,4,5
RATIONALES: The first food provided to a neonate is breast milk or formula. Between ages 4 and 6 months, rice cereal can be introduced, followed by pureed or strained fruits and vegetables, then strained or ground meat. Meats must be chopped or ground prior to feeding them to an infant to prevent choking. Infants shouldn't be given whole milk until they are at least 1 year old. Fruit drinks provide no nutritional benefit and shouldn't be encouraged. |
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A healthy, 6-month-old infant is brought to the well-baby clinic for a checkup. When assessing the infant's anterior fontanel, the nurse expects it to be:
1. open. 2. sunken. 3. closed. 4. bulging. |
1
RATIONALES: The anterior fontanel is open in a healthy, 6-month-old infant. Normally, it closes between ages 9 and 18 months. It should feel flat and firm. A sunken fontanel indicates dehydration. Although coughing or crying may cause temporary bulging, persistent bulging and tenseness of the fontanel signal increased intracranial pressure. |
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A parent is planning to enroll her 9-month-old infant in a day-care facility. The parent asks the nurse what to look for as indicators that the day-care facility is adhering to good infection-control measures. How should the nurse reply?
1. The facility keeps boxes of gloves in the director's office. 2. Diapers are discarded into covered receptacles. 3. Toys are kept on the floor for the children to share. 4. Disposable papers are used on the diaper-changing surfaces. 5. Facilities for hand washing are located in every classroom. 6. Soiled clothing and cloth diapers are sent home in labeled paper bags. |
2,4,5
RATIONALES: A parent can assess infection-control measures by appraising steps taken by the facility to prevent the spread of potential diseases. Placing diapers in covered receptacles, covering the diaper-changing surfaces with disposable papers, and ensuring that there are available sinks for personnel to wash their hands after activities are all indicators that infection-control measures are being followed. Gloves should be readily available to personnel; therefore, they should be kept in every room — not in an office. Toys typically are shared by numerous children; however, this contributes to the spread of germs and infections. All soiled clothing and cloth diapers should be placed in a sealed plastic bag before the patient is sent home. |
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The nurse is assessing an 8-month-old during a wellness checkup. Which action is a normal developmental task for an infant this age?
1. Sitting without support 2. Saying two words 3. Feeding himself with a spoon 4. Playing patty-cake |
1
RATIONALES: According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. A 15-month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old should be able to play patty-cake. |
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Which of the following is the recommended immunization schedule for diphtheria, tetanus, and pertussis (DTP)?
1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years 4. Birth, 3 months, 6 months, 12 months, and 4 to 6 years |
3
RATIONALES: According to the American Academy of Pediatrics and the Committee on Infectious Diseases, the DTP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school). The other options are incorrect. |
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A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the mother about infant nutritional needs. Which statement by the mother during the current visit indicates effective teaching?
1. "I started the baby on cereals and fruits because he wasn't sleeping through the night." 2. "I started putting cereal in the bottle with formula because the baby kept spitting it out." 3. "I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated." 4. "I'm giving the baby skim milk because he was getting so chubby |
3
RATIONALES: Iron-fortified formula supplies all the nutrients an infant needs during the first 6 months; however, fluoride supplementation is necessary if the local water supply isn't fluoridated. Before age 6 months, solid foods such as cereals aren't recommended because the GI tract tolerates them poorly. Also, a strong extrusion reflex causes the infant to push food out of the mouth. Mixing solid foods in a bottle with liquids deprives the infant of experiencing new tastes and textures and may interfere with development of proper chewing. Skim milk doesn't provide sufficient fat for an infant's growth. |
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A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them:
1. as the infant plays. 2. as the infant sleeps. 3. as the mother feeds the infant. 4. as the mother rocks the infant. |
3
RATIONALES: The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping doesn't provide an opportunity for mother-infant interaction. Although playing and rocking may provide clues about mother-infant interaction, they aren't the best activities to assess. During playing, for instance, the mother may interact with the infant at a distance. Rocking promotes closeness but not interaction; the mother can rock the infant while talking to someone else or staring off into the distance. |
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When developing a care plan for a child, the nurse identifies which Eriksonian stage as corresponding to Freud's oral stage of psychosexual development?
1. Initiative versus guilt 2. Autonomy versus shame and doubt 3. Trust versus mistrust 4. Industry versus inferiority |
3
RATIONALES: Freud defined the first 2 years of life as the oral stage and suggested that the mouth is the primary source of satisfaction for the developing child. Erikson posited that infancy (from birth to age 12 months) is the stage of trust versus mistrust, during which the infant learns to deal with the environment through the emergence of trustfulness or mistrust. Initiative versus guilt corresponds to Freud's phallic stage. Autonomy versus shame and doubt corresponds to Freud's anal/sensory stage. Industry versus inferiority corresponds to Freud's latency period. |
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A mother brings her 4-month-old to the clinic for a wellness checkup. Which immunizations should the infant receive?
1. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP), inactivated polio virus (IPV), rotavirus, and measles-mumps-rubella (MMR) 2. Haemophilus influenzae type B (Hib), rotavirus, DTaP, and IPV 3. DTaP, IPV, Hib, hepatitis B, and pneumococcal conjugate vaccine (PCV) 4. DTaP, hepatitis B, Hib, and varicella |
3
RATIONALES: DTaP, IPV, Hib, hepatitis B, and PCV are administered at ages 2 and 4 months. Rotavirus vaccine is no longer recommended because of the associated risk of intussusception. The MMR vaccine is typically administered at age 15 months. The varicella vaccine is commonly administered between ages 12 and 18 months. |
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When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which of the following restraint systems would be safest?
1. A front-facing convertible car seat in the middle of the back seat 2. A rear-facing infant safety seat in the front passenger seat 3. A rear-facing infant safety seat in the middle of the back seat 4. A front-facing convertible car seat in the back seat next to the window |
3
RATIONALES: Infants from birth to 20 lb (9.1 kg) and under age 1 must be in a rear-facing infant or convertible seat in the back seat, preferably in the middle. Infants and small children should never be placed in the front seat because of the risk of injuries from a breaking front windshield and an expanding airbag. The position next to the window isn't preferred. |
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The nurse is teaching parents how to select appropriate toys for their 10-month-old infant. Which statement by the parents indicates effective teaching?
1. "We'll get a mobile to place over the baby's crib." 2. "We'll get a rattle for the baby to play with." 3. "We'll get the baby some brightly colored blocks." 4. "We'll get the baby a push toy." |
4
RATIONALES: At age 10 months, a push toy promotes development of an infant's gross and fine motor skills and aids cognitive development. A mobile provides appropriate visual stimulation for an infant up to age 4 months; after this age, a mobile may pose a danger to an infant. Rattles and brightly colored blocks promote gross and fine motor abilities in infants ages 4 to 8 months. |
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During a well-baby visit, a mother asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first?
1. Applesauce 2. Egg whites 3. Rice cereal 4. Yogurt |
3
RATIONALES: Rice cereal is the first solid food an infant should receive because it's easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt and, finally, meat. Egg whites shouldn't be given until age 9 months because they may trigger a food allergy. |
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A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be:
1. "This is very abnormal. Your child must be sick." 2. "Let's see about further developmental testing." 3. "Don't worry, this is normal for her age." 4. "Maybe you just haven't seen her do it." |
2
RATIONALES: At age 12 months a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Options 1 and 4 aren't therapeutic and can cut off communication with the mother. Option 3 misleads the mother with false reassurance. |
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An infant, age 10 months, is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant solid foods. To help correct this problem, the nurse should:
1. point out that tongue thrusting is the infant's way of rejecting food. 2. instruct the mother to place the food at the back and toward the side of the infant's mouth. 3. advise the mother to puree foods if the child resists them in solid form. 4. suggest that the mother force-feed the child if necessary. |
2
RATIONALES: Placing the food at the back and toward the side of the infant's mouth encourages swallowing. Tongue thrusting is a physiologic response to food placed incorrectly in the mouth. Offering pureed foods wouldn't encourage swallowing, which is a learned behavior. Force-feeding may be frustrating for both the mother and child and may cause the child to gag and choke when attempting to reject the undesired food; also, it may lead to a higher-than-normal caloric intake, resulting in obesity. |
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To obtain the most accurate measurement of an infant's height (length), the nurse should measure which of the following?
1. Recumbent height with the infant lying on the side 2. Recumbent height with the infant supine 3. Recumbent height with the infant prone 4. Standing height with the infant held upright |
2
RATIONALES: 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 yield an inaccurate result until the child no longer needs assistance to stand up straight. |
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The nurse is teaching parents about the nutritional needs of their full-term infant, age 2 months, who's breast-feeding. Which response shows that the parents understand their infant's dietary needs?
1. "We won't start any new foods now." 2. "We'll start the baby on skim milk." 3. "We'll introduce cereal into the diet now." 4. "We should add new fruits to the diet one at a time." |
1
RATIONALES: Because breast milk provides all the nutrients a full-term infant needs for the first 6 months, the parents shouldn't introduce new foods into the infant's diet at this point. They shouldn't provide skim milk because it doesn't have sufficient fat for infant growth. The parents also shouldn't provide solid foods, such as cereal and fruit, before age 6 months because an infant's GI tract doesn't tolerate them well. |
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The nurse prepares to administer the Denver Developmental Screening Test to a 6-month-old infant during a well-baby checkup. This test assesses the child's:
1. intelligence quotient (IQ). 2. psychological development. 3. social, motor, and language development. 4. vision and eye muscle coordination. |
3
RATIONALES: The Denver Developmental Screening Test evaluates the developmental level of social, motor, and language skills in children ages 1 month to 6 years. It doesn't assess the child's IQ, psychological development, vision, or eye muscle coordination. |
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An infant, age 6 months, is brought to the clinic for a well-baby visit. The mother reports that the infant weighed 7 lb (3.2 kg) at birth. Based on the nurse's knowledge of infant weight gain, which current weight would be within the normal range for this infant?
1. 14 lb (6.4 kg) 2. 21 lb (9.5 kg) 3. 10.5 lb (4.8 kg) 4. 17.5 lb (7.9 kg) |
1
RATIONALES: Birth weight typically doubles by age 6 months and triples by age 12 months. Therefore, an infant who weighed 7 lb (3.2 kg) at birth should weigh 14 lb (6.4 kg) at age 6 months. |
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A mother is playing with her infant, who's sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be?
1. 6 months 2. 4 months 3. 8 months 4. 10 months |
4
RATIONALES: A 10-month-old child can sit alone and understands object permanence, so he would look for the hidden toy. Between ages 4 and 6 months, children can't sit securely alone. At age 8 months, children can sit securely alone but don't understand the permanence of objects. |
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During a well-baby visit, a 2-month-old infant receives diphtheria pertussis tetanus (DPT) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents state that the child's older brother has never received the Hib vaccine and ask why the baby must have it. How should the nurse respond?
1. "This vaccine prevents infection by various strains of the influenza virus." 2. "This vaccine protects against serious bacterial infections, such as meningitis and bacterial pneumonia." 3. "This vaccine prevents infection by the hepatitis B virus." 4. "This vaccine prevents chickenpox." |
2
RATIONALES: The Hib vaccine provides protection against serious childhood infections caused by H. influenzae type B virus, such as meningitis and bacterial pneumonia. The influenza virus vaccine provides immunity to various strains of the influenza virus. The Heptavax vaccine prevents infection by the hepatitis B virus. Chickenpox is caused by the varicella virus; a chickenpox vaccine is now available. |
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When assessing the chest of a 4-month-old infant, the nurse identifies which ratio of the anteroposterior-to-lateral diameter as normal?
1. 1:1 2. 1:3 3. 2:1 4. 3:1 |
1
RATIONALES: In an infant, the anteroposterior diameter normally equals the lateral diameter. In a toddler, the anteroposterior diameter should be less than the lateral diameter. |
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A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer?
1. "If the baby's diaper is dry when she's crying, leave her alone and she'll fall asleep." 2. "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." 3. "Leave your baby alone for 10 minutes. If she hasn't stopped crying by then, pick her up." 4. "Crying at this age indicates hunger. Try feeding her when she cries |
2
RATIONALES: The nurse should advise the mother to continue to pick the infant up when she cries because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough for her to associate crying with getting attention, it would be difficult to spoil her at this age. Even if her diaper is dry, a gentle touch may be necessary until she falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry. |
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At the health clinic, a sexually active girl, age 15, tells the nurse she's worried that her parents may find out about her sexual activity. "They would never approve," she says. The nurse should formulate which nursing diagnosis?
1. Delayed growth and development related to sexual activity 2. Impaired social interaction related to boyfriend's expectations 3. Ineffective sexuality patterns related to parent's expectations 4. Fear related to boyfriend's expectations |
3
RATIONALES: This child is expressing concerns about the conflict between her parent's expectations and her own desires. Sexual activity is a normal experimental pattern for many adolescents, but this client verbalizes parental expectations against this behavior. No evidence suggests she's having a conflict with her boyfriend or problems with social interactions. |
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Which immunization would be inappropriate for an adolescent as a component of preventative care?
1. A tetanus-diphtheria (Td) vaccine, given 10 years after the most recent childhood diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine 2. A second measles-mumps-rubella (MMR) vaccine 3. A tuberculin skin test every other year 4. The hepatitis B vaccine, if not received earlier |
3
RATIONALES: A tuberculin skin test is necessary for adolescents who have been exposed to active tuberculosis, have lived in a homeless shelter, have been incarcerated, have lived in or come from an area with a high prevalence of tuberculosis, or are currently working in a health care setting. The frequency of tuberculin testing depends on risk factors of the individual adolescents. It isn't routinely administered every other year. A Td vaccine given 10 years after the most recent childhood DTaP vaccination, a second MMR vaccine, and a hepatitis B vaccine, if not given earlier, are all recommended immunizations for adolescents. |
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A girl, age 15, is brought to the pediatrician's office by her mother, who's concerned about her daughter's dramatic weight loss over the past 2 months. The nurse suspects that the child has anorexia nervosa. Besides weight loss, nursing assessment of this client is likely to reveal:
1. insomnia. 2. dysphagia. 3. diarrhea. 4. amenorrhea. |
4
RATIONALES: Amenorrhea is common in girls and women with anorexia nervosa; researchers don't know whether it results from starvation or an underlying metabolic disturbance. Insomnia isn't associated with anorexia nervosa. Clients with anorexia nervosa are capable of eating and rarely have dysphagia (difficulty swallowing). Anorexia nervosa is more likely to cause constipation than diarrhea because limited oral intake decreases GI motility. |
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A girl, age 15, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is least effective?
1. Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model 2. Initiating a teenage-parent support group with first- and second-time mothers 3. Using audiovisual aids that show discussions of feelings and skills 4. Providing age-appropriate reading materials |
4
RATIONALES: Because adolescents absorb less information through reading, providing age-appropriate reading materials is the least effective way to teach parenting skills to an adolescent. The other options engage more than one of the senses and therefore serve as effective teaching strategies. |
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The nurse is caring for an adolescent girl who was admitted to the hospital's medical unit after attempting suicide by ingesting acetaminophen (Tylenol). The nurse should incorporate which interventions into the care plan for this client?
1. Limit care until the client initiates a conversation. 2. Ask the client's parents if they keep firearms in their home. 3. Ask the client if she's currently having suicidal thoughts. 4. Assist the client with bathing and grooming as needed. 5. Inspect the client's mouth after giving oral medications. 6. Assure the client that anything she says will be held in strict confidence. |
2,3,4,5
RATIONALES: Safety is the primary consideration when caring for suicidal clients. Because firearms are the most common method used in suicides, the client's parents should be encouraged to remove firearms from the home, if applicable. Safety also includes assessing for current suicidal ideation. In many cases, suicidal people are depressed and don't have the energy to care for themselves, so the client may need assistance with bathing and grooming. Because depressed and suicidal clients may hide pills in their cheeks, the nurse should inspect the client's mouth after giving oral medications. Rather than limit care, the nurse should try to establish a trusting relationship through nursing interventions and therapeutic communication. The client can't be assured confidentiality when self-destructive behavior is an issue. |
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According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. The nurse can best promote the development of a hospitalized adolescent by:
1. emphasizing the need to follow the facility regimen. 2. allowing parents and siblings to visit frequently. 3. arranging for tutoring in school work. 4. encouraging peer visitation. |
4
RATIONALES: Peer visitation gives the adolescent an opportunity to continue along the path toward independence and identity. Knowledge of the facility regimen prepares the adolescent for upcoming procedures but doesn't affect development. To achieve a sense of identity, the adolescent must gain independence from the family. Tutoring may help maintain a positive self-image relative to schoolwork but doesn't affect development. |
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A 15-year-old client confides in the nurse that he has been contemplating suicide. He says he has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?
1. "We can keep this between you and me, but promise me you won't try anything." 2. "I need to protect you. I will tell your physician, but we don't need to involve your parents. We want you to be safe." 3. "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." 4. "I will need to notify the local authorities of your intentions." |
3
RATIONALES: In situations in which the client is a threat to himself, the nurse can't honor confidentiality. Because this client has expressed a specific plan to commit suicide, the nurse must take immediate action to ensure his safety. The physician and mental health professionals should be notified as well as the client's family. The nurse should inform the client that she must do this, while at the same time convey a sense of caring and understanding. The local authorities don't need to be notified in this situation. |
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A nurse working on the adolescent unit has a strained working relationship with a coworker and finds it difficult to work well with her. What is the best way for her to go about diffusing this situation?
1. Get advice from other nurses assigned to the unit to see what they think might help the situation. 2. Talk with the other nurse and try to work out their differences so they don't affect client care. 3. Complain to the nurse-manager about the coworker's attitude. 4. Avoid the other nurse by working different shifts. |
RATIONALES: When personal conflicts arise, it's always best to have the two individuals try to work them out. If the differences are irreconcilable, then other trained professionals may be needed to mediate the situation. Gossiping to other nurses, complaining to the nurse-manager, and avoiding the situation by working different shifts don't help resolve the problem.
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To establish a good interview relationship with an adolescent, which strategy is most appropriate?
1. Asking personal questions unrelated to the situation 2. Writing down everything the teen says 3. Asking open-ended questions 4. Discussing the nurse's own thoughts and feelings about the situation |
3
RATIONALES: Open-ended questions allow the teen to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though he's being probed with unnecessary questions. Writing everything down during the interview can be a distraction and won't allow the nurse to observe how the adolescent behaves. Discussing the nurse's thoughts and feelings may bias the assessment and is inappropriate when interviewing any client. |
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A 15-year-old girl visits the neighborhood clinic seeking information on "how to keep from getting pregnant." What should the nurse say in response to her request?
1. "What would you like to know?" 2. "Let's discuss what your friends are doing to keep from getting pregnant." 3. "Can you tell me if you've told your parents you're having sex?" 4. "Can you tell me about the precautions you're taking now?" |
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RATIONALES: An attitude that requests only the information the girl is willing to give is nonthreatening and nonjudgmental. This may enhance the girl's willingness to talk about her experiences, thus enabling the nurse to better assess her needs. The first response assumes the girl knows what she needs to know. The precautions her friends are taking are irrelevant at this time. Reference to the girl's parents may make her defensive and fearful of help. |
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When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:
1. depression. 2. excessive sleepiness. 3. a history of cocaine use. 4. a preoccupation with death. |
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RATIONALES: An adolescent who demonstrates a preoccupation with death (such as by talking about death frequently) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also occur in adolescents who aren't suicidal. |
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Which of the following is the least effective strategy for interviewing an adolescent?
1. Maintaining objectivity by avoiding assumptions, judgments, and lectures 2. Beginning with less sensitive issues and proceed to more sensitive ones 3. Interviewing adolescents with the parents present 4. Asking open-ended questions and moving to more directive questions when possible |
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RATIONALES: When possible, adolescents should be interviewed without their parents present to ensure confidentiality and privacy. Avoid assumptions, judgments, and lectures to increase the adolescent's comfort in disclosing sensitive information. Begin with less sensitive questions so the adolescent won't feel threatened and uncomfortable and become uncooperative during the interview. Ask open-ended questions to give adolescents opportunities to share their psychosocial context. |
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At what age should boys be taught how to do a monthly testicular self-examination?
1. 8 years old 2. 12 years old 3. 16 years old 4. When they become sexually active |
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RATIONALES: Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures. |
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During a health teaching session, a student, age 14, asks the school nurse the reason for using underarm deodorant. The nurse should base the response on which physiologic change occurring during adolescence?
1. An increase in adipose tissue distribution, which boosts sweat production 2. The apocrine sweat glands reaching secretory capacity 3. The eccrine sweat glands becoming fully functional 4. The sebaceous glands becoming highly active |
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RATIONALES: The apocrine sweat glands grow in conjunction with hair follicles in the underarm areas; during adolescence, they reach their secretory capacity. Although adipose tissue increases during adolescence, this isn't associated with sweat production. The eccrine sweat glands, distributed over the entire body, aren't associated with pubertal physiologic changes. The sebaceous glands contribute to acne, not sweat production. |
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The nurse is performing a psychosocial assessment on an adolescent, age 14. Which emotional response is typical during early adolescence?
1. Frequent anger 2. Cooperativeness 3. Moodiness 4. Combativeness |
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RATIONALES: During early adolescence, a child may become moody. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence. |
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The nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent?
1. Anxiety related to separation from parents 2. Fear related to the unknown 3. Fear related to altered body image 4. Ineffective coping related to activity restrictions |
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RATIONALES: Fear related to altered body image is the most appropriate nursing diagnosis for a hospitalized adolescent because of the adolescent's developmental level and concern for physical appearance. An adolescent may fear disfigurement resulting from procedures and treatments. Separation is rarely a major stressor for the adolescent, eliminating a diagnosis of Anxiety related to separation from parents. Adolescents may have Fear related to the unknown but typically ask questions if they want information. A diagnosis of Ineffective coping related to activity restrictions may be appropriate for a toddler who has difficulty tolerating activity restrictions but is an unlikely nursing diagnosis for an adolescent. |
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When developing a care plan for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on:
1. becoming industrious. 2. establishing an identity. 3. achieving intimacy. 4. developing initiative. |
RATIONALES: According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from the family. Becoming industrious is the developmental task of the school-age child; achieving intimacy is the task of the young adult; and developing initiative is the task of the preschooler.
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An adolescent, age 16, is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask:
1. "What activities do you engage in during the day?" 2. "Do you have any allergies to foods?" 3. "Do you like yourself physically?" 4. "What kinds of foods do you like to eat?" |
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RATIONALES: Role and relationship patterns focus on body image and the client's relationship with others, which commonly interrelate with food intake. Questions about activities and food preferences elicit information about health promotion and health protection behaviors. Questions about food allergies elicit information about health and illness patterns. |
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An overweight girl, age 15, has lost 12 lb (5.4 kg) in 8 weeks by dieting. Now, after reaching a weight plateau, she has become discouraged. She and the nurse decide she should keep a food diary. What is the primary purpose of keeping such a diary?
1. To help the client stay busy and more focused on losing weight 2. To help the nurse and client analyze the amount of food the client is eating and determine when food intake occurs 3. To help the nurse and client determine whether the client has been cheating on her diet 4. To provide a written record for the client's next visit |
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RATIONALES: This client's cognitive level of formal operations will help her identify and evaluate eating behaviors of which she may not be aware. She needs to engage in other activities instead of focusing on her diet. Checking for cheating represents a punishment approach, which is relatively ineffective. The food diary is primarily for the client's benefit, although the nurse can use it, too. |
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Which situation violates a hospitalized adolescent client's right to confidentiality?
1. Two nurses talk about the adolescent on an elevator on their way to lunch. 2. The adolescent talks about his disease to another client in the hallway. 3. The physician discusses treatment plans with the adolescent in the presence of his mother. 4. The physician discusses a new medication for the adolescent while on the phone with the pharmacist. |
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RATIONALES: The elevator isn't a secure area in which to talk about clients; anyone could overhear the nurses' conversation. The client isn't breaching his own confidentiality if he volunteers the information. When the client is present for the conversation, he can object at any time to the content of the conversation. Physicians and other health care providers are expected to discuss clients and cases, as long as it's within the context of a professional relationship and is necessary for the course of treatment. |
