Chapter 20 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 20

Question 1

Type: MCSA

The nurse is plotting the height and weight of children during a school assessment clinic. Which aspect of the childrens health is the nurse assessing?

1. Development

2. Health

3. Growth

4. Bone size

Correct Answer: 3

Rationale 1: Development is an increase in the complexity of function and skill progression. It is the capacity and skill of a person to adapt to the environment.

Rationale 2: Health is a dynamic process with varying definitions, all of which point to well-being.

Rationale 3: Growth refers to physical change and increase in size. Indicators include height, weight, bone size, and dentition.

Rationale 4: Bone size is one of the indicators of growth.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Differentiate between the terms growth and development.

MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescents physiologic and psychosocial development.

Page Number: 312

Question 2

Type: MCSA

A parent brings a 16-month-old child to the clinic for a well-child checkup. During the assessment, the nurse finds that the child cannot stand next to furniture and does not try to pull himself up from a sitting position. In which process should the nurse identify that this child is lagging?

1. Growth

2. Development

3. Height

4. Behavior

Correct Answer: 2

Rationale 1: Growth is physical change and increase in size.

Rationale 2: Development is an increase in the complexity of function and skill progression. It is the behavioral aspect of growththe persons ability to walk, talk, and run, for example.

Rationale 3: Height is one of the indicators of growth.

Rationale 4: Behavior is a component of the developmental stage.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual,

socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Differentiate between the terms growth and development.

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 312

Question 3

Type: MCSA

A child is starting school and is being screened for certain developmental milestones. What is the nurse assessing when determining how the child interacts with other children?

1. Temperament

2. Physical characteristics

3. Environment

4. Culture

Correct Answer: 1

Rationale 1: Temperament is the way individuals respond to their external and internal environment and sets the stage for the interactive dynamics of growth and development.

Rationale 2: Physical characteristics include eye color and potential height and do not affect how children interact, for the most part.

Rationale 3: Environment includes family, religion, climate, culture, school, community, and nutrition and would not play as big of a role in how the child responds to peers as temperament does.

Rationale 4: Culture is part of environmental factors.

Global Rationale:

Page Reference: 355

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Explain the concept of temperament.

MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescents physiologic and psychosocial development.

Page Number: 312

Question 4

Type: MCSA

A parent is concerned that her child is unable to sit alone. The nurse explains that development is based on in-born timetables and the child will be most likely able to meet this milestone at a specific time. Upon which theory did the nurse base the response to the client?

1. Havighursts theory

2. Task theory

3. Psychosocial theory

4. Maturational theory

Correct Answer: 4

Rationale 1: Havighurst, in his developmental task theory, described growth and development occurring during six stages, each associated with 6 to 10 tasks to be learned.

Rationale 2: Havighurst, in his developmental task theory, described growth and development occurring during six stages, each associated with 6 to 10 tasks to be learned.

Rationale 3: Psychosocial theory is focused on the development of personality, not physical development.

Rationale 4: The maturational theory (Arnold Gesell) postulates that child development is a maturational process based on an in-born timetable. Although children benefit from experience, they will achieve maturational milestones such as rolling over, sitting, and walking at specific times.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe the stages of growth and development according to various theorists.

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 313

Question 5

Type: MCSA

A toddler shows fear and begins to cry when her parent leaves her at day care. According to Havighurst, which developmental task should the nurse recognize this child is exhibiting?

1. Building wholesome attitudes toward oneself

2. Learning to get along with age-mates

3. Learning to relate emotionally

4. Achieving personal independence

Correct Answer: 3

Rationale 1: This task is part of the middle childhood age period and would not be appropriate for this child.

Rationale 2: This task is part of the middle childhood age period and would not be appropriate for this child.

Rationale 3: A toddler would be in the infancy and early childhood age period, in which learning to relate emotionally to parents, siblings, and other people is a developmental task.

Rationale 4: This task is part of the middle childhood age period and would not be appropriate for this child.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify developmental tasks associated with Havighursts six age periods.

MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 316

Question 6

Type: MCSA

A parent is concerned that her 5-year-old is beginning to masturbate. How should the nurse, familiar with Freuds stages of development, respond?

1. All children are curious, but make sure the child knows that this behavior might be offensive to others.

2. You should probably consult a child psychologist if youre this concerned.

3. Lets make sure to ask your physician at the next appointment.

4. This behavior is a normal part of your childs development.

Correct Answer: 4

Rationale 1: Assuring the parent that this is a normal part of development is the best response.

Rationale 2: Assuring the parent that this is a normal part of development is the best response. This response would lead the parent to believe that the childs behavior is abnormal.

Rationale 3: Assuring the parent that this is a normal part of development is the best response. This response would lead the parent to believe that the childs behavior is abnormal.

Rationale 4: In the phallic stage, as described by Freud, which occurs from age 4 to 6 years, the childs genitals are the center of pleasure. Masturbation offers pleasure, and questions about sexual topics from parents are normal. Assuring the parent that this is a normal part of development is the best response.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Describe characteristics and implications of Freuds five stages of development.

MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescents physiologic and psychosocial development.

Page Number: 315

Question 7

Type: MCSA

A young adult has never lived away from his parents and feels unable to make decisions on his own. According to Freuds theory of development, the nurse should suspect that this person would be fixated at which stage of development?

1. Phallic

2. Latency

3. Genital

4. Anal

Correct Answer: 3

Rationale 1: The phallic stage is from 4 to 6 years of age, and fixation would be related to the individuals genital organs and the pleasure sensations they create.

Rationale 2: The latency stage is 6 years to puberty. Energy is directed to physical and intellectual activities. Sexual impulses tend to be repressed.

Rationale 3: Freuds genital stage is characterized by energy that is directed toward full sexual maturity and function and development of skills needed to cope with the environment. It occurs during puberty and extends beyond. Implications of this stage include separation from parents, achievement of independence, and decision making. Fixation occurs at any stage and is the immobilization or the inability of the personality to proceed to the next stage because of anxiety.

Rationale 4: The anal stage is from 11/2 to 3 years. The anus and bladder are the sources of pleasure (sensual satisfaction, self-control).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Describe characteristics and implications of Freuds five stages of development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 315

Question 8

Type: MCSA

A client is being seen in the mental health clinic for antisocial behavior. According to Eriksons stages of development, the nurse realizes

that this client is dealing with which task of development?

1. Initiative versus guilt

2. Industry versus inferiority

3. Intimacy versus isolation

4. Identity versus role confusion

Correct Answer: 4

Rationale 1: Initiative versus guilt is the late childhood stage and occurs from age 3 to 5 years. Industry versus inferiority occurs from 6 to 12 years, during the school-age stage.

Rationale 2: Industry versus inferiority occurs from 6 to 12 years, during the school-age stage.

Rationale 3: Intimacy versus isolation is the task during young adulthood and occurs from 18 to 25 years.

Rationale 4: According to Erik Erikson, the adolescent stage is from 12 to 20 years and the central task is identity versus role confusion. Positive resolution indicates sense of self with plans to actualize ones abilities. Negative resolution indicates feelings of confusion, indecisiveness, and possible antisocial behavior.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify Eriksons eight stages of development.

MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescents physiologic and psychosocial development.

Page Number: 316

Question 9

Type: MCSA

A client who has a terminal diagnosis has been using her time to help family members deal with her impending death. Among her activities, she collected pictures for a scrapbook and wrote a journal of favorite memories for family members to read after the client dies. According to Peck, the nurse realizes that this client is working through which developmental task?

1. Body transcendence versus body preoccupation

2. Ego transcendence versus ego preoccupation

3. Ego differentiation versus work-role preoccupation

4. Integrity versus despair

Correct Answer: 2

Rationale 1: Body transcendence versus body preoccupation calls for the individual to adjust to decreasing physical capacities and at the same time maintain feelings of well-being.

Rationale 2: Ego transcendence is the acceptance without fear of ones death as inevitable. This acceptance includes being actively involved in ones own future beyond death. Peck proposes that there are three developmental tasks during old age, in contrast to Eriksons oneintegrity versus despair.

Rationale 3: Ego differentiation versus work-role preoccupation maintains that an adults identity and feelings of worth are highly dependent on that persons work role.

Rationale 4: Erikson proposed integrity versus despair, not Peck.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Compare Pecks and Goulds stages of adult development.

MNL Learning Outcome: 2.1.4 Analyze the older adults physiologic and psychosocial development.

Page Number: 316

Question 10

Type: MCSA

A college-age client shares that he is struggling with feelings of both independence and dependence regarding his family. The nurse recognizes this as which stage of development, according to Roger Gould?

1. Stage 2

2. Stage 3

3. Stage 4

4. Stage 5

Correct Answer: 1

Rationale 1: Roger Gould studied adult development and described seven stages. Stage 2 (ages 1822) is where individuals have established autonomy, feel it is in jeopardy, and feel they could be pulled back into their families.

Rationale 2: Roger Gould studied adult development and described seven stages. Stage 3 (ages 2228) is when individuals feel established as adults and autonomous from their families. They see themselves as well defined, but still feel the need to prove themselves to their parents.

Rationale 3: Roger Gould studied adult development and described seven stages. Stage 4 (ages 2934) is when marriage and careers are well established. Individuals question what life is all about and wish to be accepted as they are, no longer finding it necessary to prove themselves.

Rationale 4: Roger Gould studied adult development and described seven stages. Stage 5 (ages 3543) is a period of self-reflection. Individuals question values and life itself. They see time as finite, with little time left to shape the lives of adolescent children.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Compare Pecks and Goulds stages of adult development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 317

Question 11

Type: MCSA

A parent reports to the nurse that his child is learning new words faster than he can write them in the baby book. According to Piaget, the nurse realizes that this child is in which phase?

1. Intuitive thought phase

2. Preconceptual phase

3. Concrete operations phase

4. Formal operations phase

Correct Answer: 2

Rationale 1: The intuitive thought phase is from age 4 to 7 years and is where egocentric thinking diminishes. The child thinks of one idea at a time and includes others in the environment.

Rationale 2: Ages 2 to 4 years, according to Piaget, is the preconceptual phase where the child uses an egocentric approach to accommodate the demands of an environment. Language development is rapid and the child associates words with objects.

Rationale 3: The concrete operations phase, ages 7 to 11, is where the child solves concrete problems. The child also begins to understand relationships such as size and right and left, and is cognizant of viewpoints.

Rationale 4: During the formal operations phase (ages 11 to 15), the child uses rational thinking, and reasoning is deductive and futuristic.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11. Explain Piagets theory of cognitive development.

MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 319

Question 12

Type: MCSA

The nurse notes that a 20-month-old child is lagging in stage 6 of Piagets phases of cognitive development. Which activity did the nurse observe that indicates that this child is struggling at this stage?

1. The child wants the same toy to sleep with during naptime and bedtime.

2. The child merely watches as the other children pretend-play.

3. The child cries when the parents leave the unit.

4. The child does not cooperate with some of the treatments.

Correct Answer: 2

Rationale 1: Ritual is important for the child of the tertiary circular reaction stage, age 12 to 18 months.

Rationale 2: In this stage of development, inventions of new means, children interpret the environment by mental images. They use make-believe and pretend-play. A child who is unable to do this would not be demonstrating the behavior that is significant at this stage.

Rationale 3: Crying when parents leave the unit and not cooperating with certain medical treatments is normal behavior for children of various ages, especially when hospitalized, and would not indicate lags in development.

Rationale 4: Not cooperating with certain medical treatments is normal behavior for children of various ages, especially when hospitalized, and would not indicate lags in development.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11. Explain Piagets theory of cognitive development.

MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 319

Question 13

Type: MCSA

The nurse is exploring the behavior of children and how they interpret right from wrong or bad from good. Which theorist should the nurse study to learn this information?

1. Vygotsky

2. Skinner

3. Kohlberg

4. Piaget

Correct Answer: 3

Rationale 1: Vygotsky explored the concept of cognitive development within a social, historical, and cultural context, arguing that adults guide children to learn and that development depends on the use of language, play, and extensive social interaction.

Rationale 2: Skinners research led to the term operant conditioning, and most of his work was with laboratory animals.

Rationale 3: Lawrence Kohlbergs theory specifically addresses the moral development of children and adults.

Rationale 4: Piaget developed the cognitive theory of development.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12. Compare Kohlbergs and Gilligans theories of moral development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 321

Question 14

Type: MCSA

A nurse educator believes that teaching students without caring about them is an exercise in futility. This educator also believes that in meeting the students needs, educators must also work to take care of themselves and care for their own needs. From which stage of Gilligans theory is the educator approaching the teaching of students?

1. Stage 1

2. Stage 2

3. Stage 3

4. Stage 4

Correct Answer: 3

Rationale 1: Stage 1 is caring for oneself.

Rationale 2: Stage 2 is caring for others.

Rationale 3: Gilligans stage 3caring for self and othersis the last stage of development, where a person sees the need for a balance between caring for others and caring for the self.

Rationale 4: Gilligan does not describe more than three stages in her theory.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Compare Kohlbergs and Gilligans theories of moral development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 22

Question 15

Type: MCSA

A nurse educator is working with students and assisting them in addressing their clients spiritual needs. The educator understands that most traditional, second-year college students are aware of their own spiritual development or working to develop their own system of spirituality. The educator realizes that the students are in which stage of Fowlers developmental theory?

1. Mythic-lyrical

2. Intuitive-projective

3. Universalizing

4. Individuating-reflexive

Correct Answer: 4

Rationale 1: Mythical-lyrical describes the person between ages 7 and 12, in a private world of fantasy and wonder.

Rationale 2: The intuitive-projective stage, ages 4 to 6 years, is a combination of images and beliefs given by trusted others, mixed with the childs own experience and imagination.

Rationale 3: Universalizing, which may never be reached by an individual, is a stage of becoming incarnate of the principles of love and justice.

Rationale 4: Fowler describes this as a stage in which the person is constructing his or her own explicit system with a high degree of self-consciousness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13. Compare Fowlers and Westerhoffs stages of spiritual development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 323

Question 16

Type: MCSA

A client with an acute, serious illness has been hospitalized. Upon entering the room, the nurse observes the client praying. The client states to the nurse: I dont know how people manage to get through difficult times without their faith. Its where I get my strength. With which theorist should the nurse associate this clients belief?

1. Fowler

2. Westerhoff

3. Gilligan

4. Kohlberg

Correct Answer: 2

Rationale 1: Fowlers theory describes the development of faith as a force that gives meaning to a persons life.

Rationale 2: Westerhoff describes faith as a way of being and behaving that evolves from an experienced faith guided by parents and others during a persons infancy and childhood to an owned faith that is internalized in adulthood. For the client who is ill, faith provides strength and trust.

Rationale 3: Gilligan is not a spiritual theorist.

Rationale 4: Kohlberg is not a spiritual theorist.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13. Compare Fowlers and Westerhoffs stages of spiritual development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 323

Question 17

Type: SEQ

The nurse is reviewing the four stages of development in Westerhoffs spiritual theory. In which order should the nurse review these stages to match the life cycle?

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Owned faith

Choice 2. Affiliative faith

Choice 3. Experienced faith

Choice 4. Searching faith

Correct Answer: 4, 2, 1, 3

Rationale 1: Puts faith into personal and social action and is willing to stand up for what the individual believes even against the nurturing community is Stage 4.

Rationale 2: Actively participates in activities that characterize a particular faith tradition; experiences awe and wonderment; feels a sense of belonging is Stage 2.

Rationale 3: Experiences faith through interaction with others who are living a particular faith tradition is Stage 1.

Rationale 4: Through a process of questioning and doubting own faith, acquires a cognitive as well as an affective faith is Stage 3.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Compare Fowlers and Westerhoffs stages of spiritual development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 323

Question 18

Type: MCSA

A nurse is working with a school-age client who is learning how to use a peak flow meter to monitor his asthma. The child has been frustrated at first, but now is able to give the reason to use the meter on a daily basis. Remembering the growth and development characteristics of the adolescent, how should the nurse respond to this client?

1. You should feel very proud for understanding and using your meter.

2. Think of using the meter as one of your daily chores.

3. Maybe you could make a game out of the daily use of your meter.

4. Its too bad if you dont want to use the meter, its just something youll have to do.

Correct Answer: 1

Rationale 1: School-age children (612 years) are in the preadolescent period, where the peer group begins to increasingly influence behavior. The nurse must allow time and energy for the school-age child to pursue hobbies and school activities and should recognize and support the childs achievement. Play and social activity are more important in the preschool-age child as new experiences and social roles are tried during play.

Rationale 2: This phrase does not support the childs growth and development.

Rationale 3: This phrase does not support the childs growth and development.

Rationale 4: This phrase does not support the childs growth and development.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe essential principles related to growth and development.

MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescents physiologic and psychosocial development.

Page Number: 314

Question 19

Type: MCSA

A nurse is working with the residents of an assisted living complex. When planning care for the old-old stage, the nurse realizes that what action will be important?

1. Provide as much care to the residents as possible.

2. Allow as much independence for the residents as possible.

3. Make sure to provide safety measures as needed.

4. Make sure the residents maintain peer interactions and social groups.

Correct Answer: 2

Rationale 1: Providing as much care as possible does not meet the independence need required in this age group.

Rationale 2: The old-old stage, age 85 and older, is characterized by increasing physical problems. The nursing implication for this age group is to assist with self-care as required, but maintain as much independence as possible.

Rationale 3: Safety measures should be applied in the middle-old age group, age 75 to 84 years.

Rationale 4: Peer interactions become important in the young-old stage, age 65 to 74 years.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe essential principles related to growth and development.

MNL Learning Outcome: 2.1.4 Analyze the older adults physiologic and psychosocial development.

Page Number: 314

Question 20

Type: MCSA

A community health nurse is planning adult health education classes. According to Eriksons stages of development, the nurse should address which task with this age group?

1. Industry versus inferiority

2. Identity versus role confusion

3. Intimacy versus isolation

4. Generativity versus stagnation

Correct Answer: 4

Rationale 1: This task is appropriate for the 6 to 12year-old schoolage child.

Rationale 2: This task is appropriate for the adolescent 12 to 20 years old.

Rationale 3: This task is appropriate for the 18- to 24yearold young adult.

Rationale 4: Adulthood, age 25 to 65 years, is characterized by the central task of generativity versus stagnation. Positive resolution is indicated by creativity, productivity, and concern for others. Negative resolution is characterized by self-indulgence, self-concern, and lack of interests and communication.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Identify Eriksons eight stages of development.

MNL Learning Outcome: 2.1.3 Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 316

Question 21

Type: MCSA

A parent brings her baby in for a well-child checkup. Which action of the child should the nurse identify as an indicator of positive resolution of the central task of this age?

1. The child does not cry when the parent allows the nurse to hold the child.

2. The child shows mistrust when strangers approach.

3. The child becomes willful when disciplined.

4. The child does not play with other children.

Correct Answer: 1

Rationale 1: In the infancy years (birth to 18 months), the childs central task is to form trust or mistrust with people. Positive resolution would indicate a safe feeling when the parents leave the child with someone they are familiar with and can trust.

Rationale 2: Positive resolution would indicate a safe feeling when the parents leave the child with someone they are familiar with and can trust. Negative resolution would indicate mistrust, withdrawal, and estrangement.

Rationale 3: Willfulness and defiance are negative indicators of the early childhood stage.

Rationale 4: Playing with other children is part of the self-esteem and self-expression of the early childhood years.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe essential principles related to growth and development.

MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 315

Question 22

Type: MCSA

A parent tells the nurse that his child is quite creative and learning how to pretend with almost anything in the house. According to Piaget, the nurse realizes this child is demonstrating which stage/phase?

1. Tertiary circular reaction: stage 5

2. Inventions of new means: stage 6

3. Preconceptual phase

4. Concrete operations phase

Correct Answer: 2

Rationale 1: Stage 5, 12 to 18 months, is characterized by discovery of new goals and ways to attain goals. Rituals are important in this stage.

Rationale 2: Stage 6, inventions of new means, is from 18 to 24 months. The significant behavior is identified by interpretation of the environment by mental image. Make-believe and pretend-play are in use during this stage.

Rationale 3: The preconceptual phase, 2 to 4 years, is when the child uses an egocentric approach to accommodate the demands of an environment.

Rationale 4: The concrete operations phase, 7 to 11 years, is where the child is able to solve concrete problems and begins to understand relationships such as size and right and left, and is cognizant of viewpoints.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11. Explain Piagets theory of cognitive development.

MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 319

Question 23

Type: MCMA

The nurse concludes that a young adult client is completing developmental tasks within Havighursts early adulthood age period. What did the nurse assess to come to this conclusion?

Standard Text: Select all that apply.

1. Taking on civic responsibility

2. Developing adult leisure-time activities

3. Getting started in an occupation

4. Relating oneself to ones spouse as a person

5. Managing a home

Correct Answer: 1, 3

Rationale 1: Taking on civic responsibilities is one of Havighursts early adulthood tasks.

Rationale 2: Developing adult leisure-time activities is not a part of the middleage period.

Rationale 3: Getting started in an occupation is one of Havighursts early adulthood tasks.

Rationale 4: Relating oneself to ones spouse as a person is not a part of the middleage period.

Rationale 5: Managing a home is one of Havighursts early adulthood tasks.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Identify developmental tasks associated with Havighursts six age periods.

MNL Learning Outcome: 2.1.3. Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 316

Question 24

Type: MCMA

The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion?

Standard Text: Select all that apply.

1. Growth involves physical change and increase in size.

2. Skills and function increase with growth.

3. Most humans experience a similar pattern of growth.

4. Being able to adapt to ones environment is an indicator of growth.

5. Childrens growth is monitored by height, weight, bone size, and dentition.

Correct Answer: 1, 3, 5

Rationale 1: Growth is physical change and increase in size.

Rationale 2: Development is an increase in the complexity of function and skill progression.

Rationale 3: The pattern of physiologic growth is similar for all people.

Rationale 4: Development skills include the ability to adapt to ones environment.

Rationale 5: Growth can be measured quantitatively. Indicators of growth include height, weight, bone size, and dentition.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe essential principles related to growth and development..

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 313

Question 25

Type: MCMA

The nurse is assessing a childs growth and development. What questions should the nurse ask the parents that demonstrate an understanding of the factors that affect growth and development processes?

Standard Text: Select all that apply.

1. How tall the parents are

2. Whether noises seem to bother their child

3. How many ounces of formula their child drinks daily

4. What their yearly income is

5. Whether their child will receive daycare services

Correct Answer: 1, 2, 3

Rationale 1: The genetic inheritance of an individual is established at conception. It remains unchanged throughout life, and determines such characteristics as gender and physical characteristics (e.g., eye color, potential height).

Rationale 2: Temperament sets the stage for the interactive dynamics of growth and development.

Rationale 3: Adequate nutrition is an essential component of growth and development.

Rationale 4: Although adequate family income allows for sufficient nutrition, housing, and other needs, it is not generally considered a factor affecting growth and development.

Rationale 5: Being cared for by individuals other than ones parents is not generally considered as a factor unless care is neglected by whoever is responsible.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 List factors that influence growth and development.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. List factors that influence growth and development.

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 312

New Questions:

Question 26

Type: MCMA

The nurse is preparing a teaching session for a group of parents with newborn children. What should the nurse include about Bowlbys attachment theory during this presentation?

Standard Text: Select all that apply.

1. Use the attachment figure as security

2. Desire to be near the attachment figure

3. Plan to separate from the attachment figure

4. Return to the attachment figure when threatened

5. Express anxiety when the attachment figure is absent

Correct Answer: 1, 2, 4, 5

Rationale 1: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include using the attachment figure as a security base.

Rationale 2: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include the desire to be near the attachment figure.

Rationale 3: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory do not include a plan to separate from the attachment figure.

Rationale 4: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include returning to the attachment figure when threatened.

Rationale 5: Bowlby believed that attachment served as a protective or survival mechanism for the infant. Characteristics of Bowlbys attachment theory include expressing anxiety (separation anxiety) when the attachment figure is absent.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10. State the four characteristics of Bowlbys attachment theory.

MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschoolers physiologic and psychosocial development.

Page Number: 319

Question 27

Type: MCMA

After analyzing behavior, the nurse determines that a client is demonstrating defense mechanisms. According to Freud, what should the nurse realize as being the cause of this behavior?

Standard Text: Select all that apply.

1. Anxiety created by conflicts

2. Activation of the conscience

3. Conflict between the ids impulses

4. Immediate pleasure and gratification

5. Underlying motivation for development

Correct Answer: 1, 3

Rationale 1: Defense mechanisms or adaptive mechanisms are the result of anxiety created by the conflicts due to social and environmental restrictions.

Rationale 2: Activation of the conscience is a function of the superego.

Rationale 3: Defense mechanisms or adaptive mechanisms are the result of conflicts between the ids impulses.

Rationale 4: Immediate pleasure and gratification is a function of the id.

Rationale 5: The underlying motivation for development is the libido.

Global Rationale: Defense mechanisms or adaptive mechanisms are the result of conflicts between the ids impulses and the anxiety created by the conflicts due to social and environmental restrictions

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: 1.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Describe characteristics and implications of Freuds five stages of development.

MNL Learning Outcome: 2.1.3. Analyze the young and middle adults physiologic and psychosocial development.

Page Number: 315

 

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