Chapter 21 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 21

Question 1

Type: MCSA

A client comes to the womens clinic, stating she has had a positive home pregnancy test. The client states that her last menstrual cycle was 2 months ago. According to this time frame, the nurse determines that the client is in which stage of pregnancy?

1. Fetal phase

2. Second trimester

3. Third trimester

4. Embryonic phase

Correct Answer: 4

Rationale 1: The fetal phase of development is characterized by a period of rapid growth in the size of the fetus and corresponds to the second trimester of pregnancy.

Rationale 2: The fetal phase of development is characterized by a period of rapid growth in the size of the fetus and corresponds to the second trimester of pregnancy.

Rationale 3: The third trimester is the last 3 months of the pregnancy period.

Rationale 4: Traditionally, pregnancy has been divided into three periods called trimesters, each of which lasts 3 months. The embryonic phase is the period during which the fertilized ovum develops into an organism with most of the features of the human. This period is considered to encompass the first 8 weeks of pregnancy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.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. Describe usual physical development from infancy through adolescence.

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

Page Number: 328

Question 2

Type: MCSA

The parents of a baby born prematurely during the sixth month of pregnancy question the nurse about the hair all over their baby. What is the nurses best response?

1. All babies are hairy. It is more noticeable on preemies.

2. Fine downy hair helps keep the baby insulated in utero.

3. You should be more concerned with the babys respiratory function.

4. Dont worry about how the baby looks. All preemies look funny.

Correct Answer: 2

Rationale 1: This option, although not incorrect, doesnt adequately address the parents question.

Rationale 2: Lanugo, a fine downy hair, covers the body of the baby and usually disappears by the time gestation is full term. Because this baby was born early, the lanugo is more noticeable and will disappear as the baby nears full term.

Rationale 3: This option dismisses the parents question.

Rationale 4: This option is insensitive and does not answer the parents question.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 329

Question 3

Type: MCSA

The nurse is preparing to instruct a client about nutritional needs before and during pregnancy. What should the nurse encourage the patient to consume in order to meet the requirements for folic acid?

1. Meats, fish, and poultry

2. A mix of vegetables and fiber

3. Oranges and green leafy vegetables

4. Lowfat and highprotein foods

Correct Answer: 3

Rationale 1: Protein sources are important for overall health but do not increase intake of folic acid.

Rationale 2: Folic acid is important to prevent neural tube defects in the fetus. Neural tube defects occur in the first few weeks of fetal development. Folic acidrich foods include green leafy vegetables, oranges, and dried beans.

Rationale 3: Folic acid is important to prevent neural tube defects in the fetus. Neural tube defects occur in the first few weeks of fetal development. Folic acidrich foods include green leafy vegetables, oranges, and dried beans.

Rationale 4: Protein sources and low-fat foods are important for overall health but do not increase intake of folic acid.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

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

Page Number: 329

Question 4

Type: MCSA

The nurse is completing a health history with a client who is 10 weeks pregnant. Which factor should the nurse identify as increasing this clients risk for a spontaneous abortion?

1. Having taken a medication that is a known teratogen

2. Smoking

3. Having low levels of folic acid

4. Genetic history

Correct Answer: 2

Rationale 1: Teratogens are medications known to adversely affect normal cellular development in the embryo or fetus.

Rationale 2: Exposure to environmental tobacco smoke has been associated with preterm births, stillbirth, miscarriage, and low-birth-weight infants.

Rationale 3: Folic acid is necessary for normal neural tube development.

Rationale 4: Genetic history does not affect the risk for spontaneous abortion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.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. Describe usual physical development from infancy through adolescence.

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

Page Number: 329

Question 5

TYPE: MCMA

The school nurse determines that a 14yearold student has reached an expected level of cognitive development. What did the nurse assess to come to this conclusion?

Standard Text: Select all that apply.

1. Thinks logically

2. Thinks about the future

3. Makes rational statements

4. Uses a trialanderror process

5. States things as they could be

Correct Answer: 1, 2, 3, 5

Rationale 1: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They are able to think logically.

Rationale 2: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They are able to think futuristically.

Rationale 3: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They are able to think rationally.

Rationale 4: A trialanderror process is a cognitive approach used by toddlers.

Rationale 5: Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development. They can conceptualize things as they could be rather than as they are.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.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 cognitive development according to Piaget from infancy through adolescence.

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

Page Number: 347

Question 6

Type: MCSA

At birth a baby weighed 8 lb. What should the nurse expect this baby to weight at the age of 1?

1. 32 lb

2. 16 lb

3. 20 lb

4. 24 lb

Correct Answer: 4

Rationale 1: This weight is above the expected weight for this infant at 1 year of age..

Rationale 2: This weight is well below the expected weight for this infant at 1 year of age.

Rationale 3: This weight is below the expected weight for this infant at 1 year of age.

Rationale 4: Normal growth patterns dictate that infants usually reach three times their birth weight by 12 months, and twice their birth weight at 6 months. They typically gain weight at a rate of 5 to 7 ounces weekly for 6 months.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.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. Describe usual physical development from infancy through adolescence.

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

Page Number: 330

Question 7

Type: MCSA

Parents of a newborn ask the nurse why their newborns head seems lopsided and not round, as they thought it should be. How should the nurse respond to these parents?

1. I dont think it looks unusual; actually the head is beautifully shaped.

2. Your babys head had to shape itself to the birth canal. It will look round in a few days.

3. Youre right. Well make sure your doctor checks this out.

4. Babies heads always look funny. Once his hair grows out, youll hardly notice it.

Correct Answer: 2

Rationale 1: This option dismisses the parents concerns.

Rationale 2: Molding of the head is made possible by the fontanels and occurs during vaginal deliveries as the head comes through the birth canal. Within a week, the newborns head usually regains its symmetry. It is normal with vaginal deliveries. Babies born via cesarean section do not experience molding. Molding is not permanenta fact that makes parents feel more reassured.

Rationale 3: This condition is not abnormal and does not need to be referred to the doctor; rather, the nurse needs to reassure the parents that nothing is wrong.

Rationale 4: This option is not necessarily true, nor does it adequately address the parents concerns.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 331

Question 8

Type: MCSA

The parents of a newborn ask what their baby can see. What should the nurse respond to these parents?

1. Babies arent able to see until they are around 4 months old.

2. Babies wont track moving objects until about 5 months.

3. Newborns blink in response to bright lights and sound and will follow large objects.

4. Newborns arent able to focus, so everything looks blurry to them.

Correct Answer: 3

Rationale 1: This is not necessarily correct information because we dont know what they see or how it looks to them.

Rationale 2: At 5 months, the infant reaches for objects, but starts tracking them much sooner.

Rationale 3: Newborns can follow large, moving objects and blink in response to bright lights and sound. Their pupils respond slowly, and the eyes cannot focus on close objects. We dont know what they see or how it looks to them.

Rationale 4: We dont know what newborns see or how it looks to them.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 331

Question 9

Type: MCSA

The parents of a newborn male ask the nurse about pain during circumcision. What should the nurse respond to these parents?

1. Newborns cant feel pain, so dont worry about it.

2. Well make sure to bring your baby to you right after the procedure, so you can comfort him.

3. Ill have the pediatrician speak to you about it.

4. Newborns pain experience is real. Well use some medication to help your baby feel more comfortable.

Correct Answer: 4

Rationale 1: Newborns certainly do feel pain.

Rationale 2: Newborns certainly do feel pain and it is important to comfort the child, but this option does not answer the parents question. Nurses who care for newborns should be able to explain expected reactions to the parents.

Rationale 3: Nurses who care for newborns should be able to explain expected reactions to the parents.

Rationale 4: Young babies react diffusely to pain and cannot isolate the discomfort. The pain of circumcision is not isolated in the genital region, but may be felt more diffusely, throughout the body.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 332

Question 10

Type: MCMA

An expectant parent asks the nurse about health problems of newborns. On what should the nurse provide information to this client?

Standard Text: Select all that apply.

1. Infant colic

2. Respiratory tract infections

3. Failure to thrive

4. Injuries

5. SIDS

Correct Answer: 1, 3, 5

Rationale 1: Health problems of newborns include infant colic.

Rationale 2: Respiratory tract infections are more common for toddlers and school-age children.

Rationale 3: Health problems of newborns include failure to thrive.

Rationale 4: Injuries are more problematic as the child grows, especially in the school-age child.

Rationale 5: Health problems of newborns include SIDS.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 333

Question 11

Type: MCSA

New parents ask if their 8monthold baby is performing activities that are expected at this age. What should the nurse suggest to screen this babys developmental level?

1. The Denver Developmental Screening Test (DDST-II)

2. Growth and development charts from the Centers for Disease Control and Prevention (CDC)

3. Assessment tools utilized by the state education department

4. The Apgar scoring system

Correct Answer: 1

Rationale 1: The Denver Developmental Screening Test (DDST-II) can be used to assess the infants behavior and can be used from birth to 6 years. It is intended to estimate the abilities of a child compared to those of an average group of children of the same age.

Rationale 2: The CDC utilizes growth charts for physical assessment, but these do not address developmental issues.

Rationale 3: The school system assessment tools would be focused on the school-age child.

Rationale 4: The Apgar scoring system is used to provide information about the babys physiologic adaptation within minutes after birth.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.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. Identify tasks characteristic of different stages of development from infancy through adolescence.

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

Page Number: 335

Question 12

Type: MCSA

The parents of a toddler are concerned that their child is so messy during eating, so they feed him instead of allowing him to feed himself. What should the nurse respond to the parents?

1. Thats probably best. Im sure it makes your mealtime more pleasant.

2. At least youre sharing meals as a family. Thats the most important.

3. Motor skills keep improving with age. Try not to get frustrated with the mess.

4. Your child will never learn if you dont let him experience.

Correct Answer: 3

Rationale 1: This option reflects parental action that will interfere with the childs development; assuring the parents that this will improve may help them with their patience during the messy times.

Rationale 2: This option does not address the developmental need for the child to attempt feeding himself.

Rationale 3: Fine muscle coordination and gross motor skills improve during toddlerhood. At 2 years, the toddler should be able to hold a spoon and put it into the mouth correctly, albeit with some messes while he is learning. Assuring the parents that this will improve may help them with their patience during the messy times.

Rationale 4: Simply doing the skill for the child will allow no room for practice and error. However, the nurse must be careful in how this is worded, so as not to sound scolding to the parents.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence.

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

Page Number: 336

Question 13

Type: MCSA

A toilettrained 4-year-old hospitalized for several days with an acute illness has been wetting the bed at night and is having incontinent accidents during the day. How should the nurse address the parents concern about this behavior?

1. Maybe your child should be seen by a specialist, just to make sure there are no physical problems.

2. It is normal for some children to go through a stage of regression after separation from their family or after an acute illness. Try not to be too discouraged.

3. Youll have to be very strict with discipline, so your child knows this behavior is not acceptable.

4. Id be upset too. It must be hard to go back to using diapers.

Correct Answer: 2

Rationale 1: Regressive behavior is not based on physiology and, unless it lasts, would not have to be further investigated.

Rationale 2: Regression is reverting to an earlier development stage (bed-wetting, using baby talk, etc.) as part of the childs experiences with separation anxiety. Nurses can assist parents by helping them understand that this behavior is normal and will pass as the child reestablishes herself as part of the family and works through her own frustration with the situation.

Rationale 3: Strict discipline may not be the best solution over understanding and caring.

Rationale 4: This option does not provide the parents with an understanding of the root of the problem.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence.

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

Page Number: 337

Question 14

Type: MCSA

A kindergarten class is being screened by a group of nursing students using a Snellen E chart. Few of the children have 20/20 vision. Most have 20/30, and some have 20/40. What should the nursing students report to the instructor about these childrens vision?

1. These children have normal vision abilities.

2. We should check into the health of these children. Maybe their diets are lacking in essential vitamins because they all have poor eyesight.

3. These kids will all be wearing glasses when we come back next year.

4. We should use a different eye chart. Maybe the kids would understand it better.

Correct Answer: 1

Rationale 1: Preschool children are generally farsighted and not able to focus on near objects. By the end of the preschool years, visual ability has improved. Normal vision for the 5-year-old is 20/30.

Rationale 2: Unless there are other concerns, these findings should be considered normal and further investigation would be unnecessary.

Rationale 3: This option does not reflect an understanding of normal physical development of a child.

Rationale 4: The Snellen E chart should be used to assess the preschoolers vision.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 338

Question 15

Type: MCSA

During an auditory screening of third graders, the school nurse identifies a hearing deficit for one of the students. When the parents ask the nurse about the findings, how should the nurse respond?

1. Hearing acuity is not fully developed in your child. Lets recheck next year.

2. Id like to recheck at the clinic. Then we may need to have your child be seen by an auditory specialist.

3. It was too noisy when we were testing, so I wouldnt be concerned if I were you.

4. Your child will probably need a hearing aid.

Correct Answer: 2

Rationale 1: The followup for these findings should not be postponed.

Rationale 2: Auditory perception is fully developed in school-age children, who are able to identify fine differences in voices, both in sound and pitch. Rechecking the results with a possible referral would be appropriate at this level.

Rationale 3: Auditory testing should be done in a quiet environment or none of the testing is accurate.

Rationale 4: The childs hearing test could be affected by a number of physiological variables (e.g., recent respiratory illness or excess cerumen in the ears), and telling the parents their child needs a hearing aid is both premature and not within the nurses realm of practice.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 339

Question 16

Type: MCSA

A school nurse is working with teachers in helping them address the developmental needs of grade school students, according to Eriksons theory of industry versus inferiority. Which activities should the nurse suggest?

1. Providing time for running and playing sports, such as basketball, to increase gross motor skills

2. Allowing pretend time during their classes, such as for dress-up or role-playing activities

3. Presenting diversity in culture and practices as part of classroom study

4. Helping them develop skills needed in the adult world, such as allowance budgeting

Correct Answer: 4

Rationale 1: Gross motor skills should be the focus of the preschool child. Understanding diversity, role preference, and performance is the task of the adolescent.

Rationale 2: Make-believe and pretend opportunities should be the focus of the preschool child.

Rationale 3: Understanding diversity, role preference, and performance is the task of the adolescent.

Rationale 4: School-age children are motivated by activities that provide a sense of worth. They concentrate on mastering skills that will help them function in the adult world.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Trace psychosocial development according to Erikson from infancy through adolescence.

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

Page Number: 342

Question 17

Type: SEQ

The parents of a schoolage child are concerned about the child learning right from wrong. In which order should the nurse instruct the parents of a school-age child that moral development will develop in their child?

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

Choice 1. Punishment and obedience

Choice 2. Law-and-order orientation

Choice 3. Instrumental-relativist orientation

Choice 4. Good boynice girl stage

Correct Answer: 1, 4, 2, 3

Rationale 1: School-age children are in Kohlbergs stage 1 of the preconventional level (punishment and obedience); that is, they act to avoid being punished.

Rationale 2: Stage 4 is the lawandorder orientation. The motivation for moral action at this stage is to live up to what significant others think of the child.

Rationale 3: Stage 2 is the instrumental-relativist orientation. These children do things to benefit themselves. Fairness, in which everyone gets a fair share or chance, becomes important.

Rationale 4: Stage 3 is the good boynice girl stage. The child shifts from the concrete interests of individuals to the interests of groups.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe moral development according to Kohlberg from childhood through adolescence.

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

Page Number: 343

Question 18

Type: MCSA

A school health nurse is working on education programs for high school students. As part of the plan, the nurse wants to address health concern topics besides the dangers of unprotected sex or drug and alcohol abuse. Which class topic should the nurse present to these students?

1. Warning signs of depression for peers to identify among their classmates

2. Injury prevention

3. Early signs of cancer and heart disease

4. Normal physiological changes of this age group

Correct Answer: 1

Rationale 1: Suicide in adolescents has declined in recent years, but continues to be a significant problem. Older adolescents, males, and non-Hispanic American Indians and Alaskan Natives have the highest rates of suicides among adolescents. Suicide by an adolescent may be reported as an accidental death. Motor vehicle crashes, drug and alcohol overdoses, firearm injuries, and even homicides can be disguised suicides. Psychological, social, and physiological stressors are apparent causes for many suicides. Students would benefit from understanding what to look for in their peers.

Rationale 2: Injury prevention should be the focus in the school-age child.

Rationale 3: Cancer and heart disease are not prevalent problems among highschoolage students.

Rationale 4: Normal physiological changes would not address the health problems of this age group, but rather would give general information.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

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

Page Number: 348

Question 19

Type: MCSA

While the nurse is teaching a group of parents and their teenage sons about puberty and sexual growth, a parent asks if fertility coincides with ejaculation. What should the nurse respond to this question?

1. Yes, if your son is ejaculating, he also possesses fertility.

2. Sexual maturity does not occur until age 18, so dont worry about anything until then.

3. Fertility follows several months after the first ejaculation.

4. Youll have to ask your physician about this because it is a sensitive subject.

Correct Answer: 3

Rationale 1: Ejaculation does not mean the same thing as fertility, which does occur before sexual maturity.

Rationale 2: Fertility follows several months later, with sexual maturity achieved by age 18. Ejaculation does not mean the same thing as fertility, which does occur before sexual maturity.

Rationale 3: The milestone of male puberty is considered to be the first ejaculation, which commonly occurs at about 14 years of age. Fertility follows several months later, with sexual maturity achieved by age 18.

Rationale 4: The nurse, in presenting topics of a sensitive nature, should be able to answer questions regarding the topic, not refer the audience to a physician.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 345

Question 20

TYPE: MCMA

The nurse suspects that an adolescent is working through the stages of spiritual development. What observations did the nurse make to come to this conclusion?

Standard Text: Select all that apply.

1. Imitated behavior demonstrated by parents

2. Conceptualized angels and devils with the use of imagination

3. Compartmentalized differences between spiritual beliefs with friends

4. Determined differences between spiritual beliefs as being right or wrong

5. Met with the church priest to talk about the differences in spiritual beliefs

Correct Answer: 3, 4, 5

Rationale 1: Imitating behavior demonstrated by parents is a behavior of a preschoolage child.

Rationale 2: Conceptualizing angels and devils with the use of imagination is a behavior demonstrated by a preschoolage child.

Rationale 3: The adolescent may reconcile differences in spiritual beliefs by compartmentalizing the differences.

Rationale 4: The adolescent may reconcile differences in spiritual beliefs by deciding which differences are right or wrong.

Rationale 5: The adolescent may reconcile differences in spiritual beliefs by obtaining advice from a priest.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.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: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 347

Question 21

Type: MCSA

A teenage girl spends most of her free time with friends. In sharing their concerns about this behavior with the school nurse, the parents are worried about their child seeming to draw away from them. What should the nurse respond to the parents?

1. You should really keep better track of your child. Its hard to tell what kinds of trouble she may be getting into.

2. Independence is really important for this age group. Try to be extra attentive when your child does spend time at home.

3. Use stricter guidelines for curfew and punishment if curfew is broken.

4. Is it possible that your child might be taking drugs?

Correct Answer: 2

Rationale 1: This option reflects any overly pessimistic view regarding the childs behavior.

Rationale 2: Many adolescents gradually draw away from the family and gain independence. This sometimes creates conflict within the family. The young person may appear hostile or depressed. It is not uncommon for adolescents to prefer to be with their peers rather than their families.

Rationale 3: Parents should try not to increase controls, as this may cause more rebellion in the child.

Rationale 4: This option reflects any overly pessimistic view regarding the childs behavior.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify tasks characteristic of different stages of development from infancy through adolescence.

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

Page Number: 345

Question 22

Type: MCSA

An adolescent comes to the school nurses office seeking advice about his friends and feeling pressure to participate in activities with which he isnt comfortable, such as drinking parties and sexual explorations. What should the nurse do?

1. Tell the adolescent to stay away from friends like that.

2. Be open to the concerns and provide accurate information about any questions.

3. Encourage the adolescent to accept psychosocial counseling.

4. Give the adolescent pamphlets on sexually transmitted diseases.

Correct Answer: 2

Rationale 1: Giving directions may turn the student away from seeking help.

Rationale 2: The nurse must present an open, accepting attitude to the adolescents questions while encouraging the adolescent to find relationships that promote discussion of feelings, concerns, and fears.

Rationale 3: Suggesting counseling may turn the student away from seeking help.

Rationale 4: Just giving written information on a particular topic will not address the complete situation the student seeks assistance with.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

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

Page Number: 345

Question 23

Type: MCSA

A nurse is teaching a class to new parents on how to handle some of the behaviors that could be demonstrated by toddlers. One of the parents asks what to do when her child throws a temper tantrum. How should the nurse respond to this parent?

1. Try to be more attentive to the behaviors that lead into a tantrum. Then you can avoid them.

2. Put the child in a room alone and ignore the tantrum.

3. Make sure the child is safe, then walk away.

4. Hold the child tightly until he stops crying.

Correct Answer: 3

Rationale 1: Sometimes, even with all the best intentions, toddlers throw tantrums. Parents should not be made to feel like it was something they did wrong or could have prevented.

Rationale 2: Placing the child away from supervision (in a room alone) could increase the risk of injury.

Rationale 3: Making sure of safety, then walking away is part of fostering the toddlers psychosocial development.

Rationale 4: Holding the child tight will only add to the childs frustration and possibly increase the behavior.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

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

Page Number: 336

Question 24

Type: MCSA

A school nurse is implementing a program to promote psychosocial development among adolescent teens at a high school. Which activity should the nurse include?

1. Career planning

2. Establishing peer groups

3. Playing musical instruments

4. Determining a value system

Correct Answer: 4

Rationale 1: Appropriate psychosocial activities for the adolescent include activities to stimulate interest in careers.

Rationale 2: Establishing peer groups would be part of psychosocial development of the school-age child.

Rationale 3: Learning to play a musical instrument would be motor development for the school-age child.

Rationale 4: Appropriate psychosocial activities for the adolescent include activities to help establish an appropriate value system.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

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

Page Number: 346

Question 25

Type: MCSA

A baby was born with flaccid muscle tone, regular respirations with crying, a heart rate of 85, and blue extremities. What would the Apgar score be?

1. 6

2. 7

3. 5

4. 8

Correct Answer: 1

Rationale 1: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6.

Rationale 2: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6.

Rationale 3: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6.

Rationale 4: Flaccid muscle tone = 0. Regular respirations = 2. Crying = 2. Heart rate of 85 = 1. Blue extremities = 1. Total = 6.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.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. Describe usual physical development from infancy through adolescence.

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

Page Number: 334

Question 26

Type: MCMA

The nurse is preparing a teaching session for pregnant clients that reviews the fetal growth and development that occurs in the first 3 weeks post-conception. What should the nurse include in this teaching?

Standard Text: Select all that apply.

1. How the embryo has attached to the wall of the uterus

2. Development of the fetal membranes and the amniotic sac

3. How the embryo will be covered with a protective substance called vernix caseosa

4. How development of the fetal placenta has begun

5. How the embryo is covered with a soft, downy hair

Correct Answer: 1, 2, 4

Rationale 1: Events occurring concurrently during the first 3 weeks include the embryos being implanted in the endometrium of the uterus.

Rationale 2: Events occurring concurrently during the first 3 weeks include fetal membranes differentiating into the chorionthe precursor to the placentaand the amnion, the precursor to the amniotic sac.

Rationale 3: At the end of the second trimester, or 6 lunar months, a protective covering called vernix caseosa begins to develop over the skin.

Rationale 4: Events occurring concurrently during the first 3 weeks include the function of the placenta.

Rationale 5: At the end of the second trimester, or 6 lunar months, lanugoa fine downy haircovers the body.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

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

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

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

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Describe usual physical development from infancy through adolescence.

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

Page Number: 328

Question 27

Type: MCMA

The nurse is confident that a client has met the developmental guidelines for a preschooler. What did the nurse assess to make this clinical decision?

Standard Text: Select all that apply.

1. Can print her own name.

2. Proudly announces, I put my own toys away.

3. Shares that, I know I shouldnt hit, even when Im mad.

4. Effectively brushes her own teeth.

5. Washes her hands after toileting without prompting.

Correct Answer: 1, 2, 4

Rationale 1: Development is assessed when the child is able to print letters and numbers by 5 years of age.

Rationale 2: Development is assessed when the child is able to cooperate in doing simple chores by 5 years of age.

Rationale 3: This is a developmental task more appropriate for school-age children.

Rationale 4: Development is assessed when the child is able to perform simple hygiene measures by 5 years of age.

Rationale 5: This is a developmental task more appropriate for a school-age child.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.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 assessment activities and expected characteristics from birth through late childhood.

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

Page Number: 339

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