term1 Definition1term2 Definition2term3 Definition3
Please sign in to your Google account to access your documents:
The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child’s desire to accomplish which of the following?
Select one:
a. Increase their independence.
b. Finish a project they set out to do.
c. Gratify their oral fixation.
d. Develop their sense of trust.
The correct answer is: Increase their independence.
At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response?
a. This is a possible infection or irritation in the genital area
b. Your child is probably imitating behaviors that she has observed
c. Awareness of body structures and sensations is normal and expected
d. This is an early emergence of sexual expression that should be discouraged
Answer
Awareness of body structures and sensations is normal and expected
CORRECT. Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! It should be ignored unless the behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come and do some fun and exciting activity
A nurse is taking the health history of a school-age girl. Which statement by the client’s mother indicates a need for further teaching regarding the client’s nutritional status?
a. “We increase her protein intake when she’s playing sports.”
b. "She enjoys helping to prepare her snacks in the kitchen.”
c. “We allow her to pick out a treat at the grocery store for good behavior.”
d. “She eats a large breakfast every morning.”
CORRECT. This statement indicates a need for further teaching. This client’s mother should be educated about the importance of praising the client’s abilities and skills rather than using food as a reward, which may lead to an increased risk for obesity.
A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client?
a. The infant is unable to point to objects
b. The infant does not raise his head when placed on his abdomen
c. The infant demonstrates stranger anxiety
d. The infant is unable to sit with support
CORRECT. When placed on the abdomen the 3 month old should attempt to raise his head. Some sources refer to this as “tummy time” which provides the infant with the stimulation to strengthen upper body and neck muscles in preparation for good head control when sitting upright and the some of the muscles required for crawling.
A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention?
a. The baby develops a localized or generalized rash
b. The baby develops swelling or redness at the injection site
c. The baby has an axillary temperature of 100.4o F. (38o C)
d. The baby is crying inconsolably for more than three hours
CORRECT. Inconsolable crying lasting more than three hours and/or seizures within 48 hours of vaccination is a sign of encephalopathy that must be treated immediately.
A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported?
a. Abdominal distension
b. Mild diarrhea
c. Decreased urine output
d. Difficulty evacuating bowels
CORRECT. Decreased urine output indicates dehydration and should be reported immediately to the provider. Listlessness, sunken eyes, decreased tears, and dry mucous membranes are other symptoms of dehydration that should be immediately reported.
A nurse is changing a dressing on a pre-school-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child?
a. Encouraging the child to watch a favorite cartoon on television.
b. Assisting the child to take deep breaths and focus on relaxing.
c. Promising the child a special treat in exchange for cooperation.
d. Teaching the child how to go ‘to a different place’ using their imagination.
CORRECT. Cartoons would be a very attractive distraction, and distraction is a powerful nonpharmacologic comfort intervention which works well with this developmental age.
A nurse is planning community education focusing on the principles of first aid. Which of the following strategies is likely to be most effective with adolescent learners?
a. Divide the planned program into several sessions over several weeks.
b. Actively involve the participants in practice of techniques.
c. Teach the most crucial content early in the session.
d. Simple lecture format.
Adolescent learners will learn best when actively involved in participation and use of psychomotor skills.
A nurse is providing education to the mother of a ten year old child about to undergo scoliosis screening. Which of the following statements by the mother indicates a need for further teaching?
a. “The examiner will be looking for symmetry in alignment of shoulders or hips.”
b. “My child should be undressed down to her under wear.”
c. “My child will be asked to stand upright, arms stretched above the head.”
d. “The examiner will be looking for asymmetry of the ribs and flanks.”
Screening is done by observing the child from the back while they are wearing only underwear in order to best visualize the anatomical abnormalities associated with scoliosis.
A nurse is collecting data on newborn. Which of the following is an expected finding?
a. Babinski reflex present
b. Pulse rate 70 to 80/min
c. Decorticate reflex
d. Respirations 21 to 24/min
a. Babinski reflex present The Babinski reflex is present for the first year of life. The reflex is elicited by stroking the outer edge of the sole of an infant’s foot up toward the toes. The infant’s toes fan upward and out.
Need help typing ? See our FAQ (opens in new window)
Please sign in to create this set. We'll bring you back here when you are done.
Discard Changes Sign in
Please sign in to add to folders.
Sign in
Don't have an account? Sign Up »
You have created 2 folders. Please upgrade to Cram Premium to create hundreds of folders!