Chapter 21 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/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 client would be in which of the following?

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: Page Reference: 373

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 2

Type: MCSA

A baby was born prematurely during the sixth month of pregnancy. The new parents question the nurse about the hair all over their baby. The nurses best response is:

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 while 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. Since 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: Page Reference: 373

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 3

Type: MCSA

The client asks about nutritional needs before and during pregnancy. The nurse responds by telling the client she should increase her intake of which of the following food groups 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. Foods containing low fat and high protein

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. The neural tube defect occurs in the first few weeks of fetal development. Folic-rich foods include green leafy vegetables, oranges, and dried beans. Clients should also be encouraged to take a vitamin supplement that contains folic acid. Vegetables in general and fiber are important for overall health but do not increase intake of folic acid.

Rationale 3: Folic acid is important to prevent neural tube defects in the fetus. The neural tube defect occurs in the first few weeks of fetal development. Folic-rich 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: Page Reference: 373

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

Question 4

Type: MCSA

. Which of the following factors would indicate that the client was at risk for a spontaneous abortion?

1. Taking a medication that was 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: Smoking has been associated with preterm labor, spontaneous abortion, low-birth-weight infants, sudden infant death syndrome, and learning disorders.

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: Page Reference: 374

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 5

Type: MCSA

A nursing student studying the fetal development and growth process asks the instructor why the first 3 months after birth are referred to as the fourth trimester, since this term refers to the pregnancy period. The educator replies:

1. Since its part of the babys first year, it is combined with the pregnancy period.

2. The babys major task is adjustment and he or she is very vulnerable during the first 3 months following delivery.

3. The babys birth weight is changing so rapidly that this time period is considered growth as during pregnancy.

4. It is in correlation with their developmental stage, as described by Freud.

Correct Answer: 2

Rationale 1: This is not the recognized reason for the use of this term.

Rationale 2: A newborns basic task is adjustment to the environment as an individual. This makes them very vulnerable to the outside world. This stage is referred to, by some, as the fourth trimester.

Rationale 3: This is not the recognized reason for the use of this term.

Rationale 4: Freuds developmental stage for this age group is the oral stage, since many of the infants activities and pleasures are mouth centered.

Global Rationale: Page Reference: 374

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 6

Type: MCSA

At birth a baby weighed 8 lb. If she is following normal growth and development patterns, what should her weight be at 1-year-old?

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: Page Reference: 374

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

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. The nurses best response is:

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 but rather the nurse needs to reassure the parents that nothing is wrong.

Rationale 4: This option is not necessarily true nor does it adequatelyanswer the paents concerns.

Global Rationale: Page Reference: 375

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 8

Type: MCSA

The parents of a newborn ask the nurse about what their baby can see. The nurse responds correctly by saying:

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 since 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 what newborns see or how it looks to them.

Global Rationale: Page Reference: 376

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 9

Type: MCSA

The parents of a newborn male ask the nurse about pain during circumcision. The nurse correctly responds with which of the following?

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: Page Reference: 376

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 10

Type: MCSA

An expectant parent asks the nurse about health problems of newborns. The nurse will provide information on which of the following?

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, failure to thrive, and SIDS. Respiratory tract infections are more common for toddlers and in the school-age child. Injuries are more problematic as the child grows, especially in the school-age child.

Rationale 2: Health problems of newborns include infant colic, failure to thrive, and SIDS. Respiratory tract infections are more common for toddlers and in the school-age child. Injuries are more problematic as the child grows, especially in the school-age child.

Rationale 3: Health problems of newborns include infant colic, failure to thrive, and SIDS. Respiratory tract infections are more common for toddlers and in the school-age child. Injuries are more problematic as the child grows, especially in the school-age child.

Rationale 4: Health problems of newborns include infant colic, failure to thrive, and SIDS. Respiratory tract infections are more common for toddlers and in the school-age child. Injuries are more problematic as the child grows, especially in the school-age child.

Rationale 5: Health problems of newborns include infant colic, failure to thrive, and SIDS. Respiratory tract infections are more common for toddlers and in the school-age child. Injuries are more problematic as the child grows, especially in the school-age child.

Global Rationale: Page Reference: 378

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 11

Type: MCSA

New parents are concerned about the things their baby is and is not doing at age 8 months. The nurse might suggest screening the baby with which of the following?

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

2. Growth and development charts from the Center of Disease Control (CDC)

3. Assessment tools utilized by the state education department

4. 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: Page Reference: 379

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Identify tasks characteristic of different stages of development from infancy through adolescence.

Question 12

Type: MCSA

The parents of a toddler are concerned that their child is so messy during eating, so they just feed him. The nurses best response is to state::

1. Thats probably best. Im sure it makes your meal time 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 developemental 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: Page Reference: 376

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Identify tasks characteristic of different stages of development from infancy through adolescence.

Question 13

Type: MCSA

A toilet trained 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. The nurse addresses the parents concerns with the following statement:

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: Page Reference: 381

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Identify tasks characteristic of different stages of development from infancy through adolescence.

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 observation would the nursing students make to their instructor?

1. These children have normal vision abilities.

2. We should check into the health of these children. Maybe their diet is lacking in essential vitamins since 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: Page Reference: 380

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

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, the nurse should 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 have to have your child 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 follow up 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 (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: Page Reference: 380

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

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. The nurse suggests which of the following activities?

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

2. Allowing pretend time during their classes, like dress-up or role-playing

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

4. Helping them develop skills needed in the adult world, like 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: Page Reference: 387

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Trace psychosocial development according to Erikson from infancy through adolescence.

Question 17

Type: SEQ

According to Kohlbergs moral developmental theory, school-age children progress through several stages of their development. Put the following stages in order, from 1 to 4.

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 boy-nice girl stage

Correct Answer: 1,4,2,3

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

Rationale 2: Stage 4 is the law and order 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 (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 boy-nice girl stage. The child shifts from the concrete interests of individuals to the interests of groups.

Global Rationale: Page Reference: 388

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Describe moral development according to Kohlberg from childhood through adolescence.

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 would be appropriate to present?

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: The 2003 Youth Risk Behavior Surveillance reported that most deaths in the age group from 10 to 24 years were caused by motor vehicle crashes, unintentional injuries (falls, drowning, poisoning), homicides, and suicides. Risky behaviors contributed to these statistics, but since suicide is one of the four major causes of death in this age group and depression or depressed behavior often leads to this end, it would be good if students understood 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 high school age students.

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

Global Rationale: Page Reference: 394

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

Question 19

Type: MCSA

The school nurse is teaching a group of parents and their teenage sons about puberty and sexual growth. A parent asks the nurse,, Does fertility coincide with ejaculation? The nurse replies:

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 since 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 referring the audience to a physicians opinion.

Global Rationale: Page Reference: 390

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 20

Type: MCSA

A school nurse is counseling adolescents about risks for STDs. Using recent statistics, the nurse presents information that the number of new cases of STDs in this age group, each year, will be approximately:

1. 1 million

2. 2 million

3. 3 million

4. 4 million

Correct Answer: 4

Rationale 1: According to statistics from the U.S. Department of Health and Human Services (2000), almost 4 million of the new cases of sexually transmitted diseases (STDs) each year occur in adolescents.

Rationale 2: According to statistics from the U.S. Department of Health and Human Services (2000), almost 4 million of the new cases of sexually transmitted diseases (STDs) each year occur in adolescents.

Rationale 3: According to statistics from the U.S. Department of Health and Human Services (2000), almost 4 million of the new cases of sexually transmitted diseases (STDs) each year occur in adolescents.

Rationale 4: According to statistics from the U.S. Department of Health and Human Services (2000), almost 4 million of the new cases of sexually transmitted diseases (STDs) each year occur in adolescents.

Global Rationale: Page Reference: 393

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

Question 21

Type: MCSA

A teenage girl spends most of her free time with friends or at school. Sharing their concerns about this behavior with the school nurse, the parents are worried about their child seeming to draw away from them. The nurses best reply is:

1. You should really keep better track of your child. Its hard to tell what kinds of trouble they 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: Speaking with the child openly about concerns, the parents should be encouraged to provide a safe, secure home environment with enough freedom that the adolescent can appreciate.

Global Rationale: Page Reference: 391-392

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Identify tasks characteristic of different stages of development from infancy through adolescence.

Question 22

Type: MCSA

An adolescent comes to the school nurses office seeking advice about his friends and feeling pressure to participate in activities he isnt comfortable with (i.e., drinking parties and sexual explorations). The nurse should:

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 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 from seeking help.

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

Global Rationale: Page Reference: 391

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

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 their child throws a temper tantrum. The nurse should reply:

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 possible increase the behavior.

Global Rationale: Page Reference: 381

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

Question 24

Type: MCSA

A school nurse is implementing a program to promote psychosocial development among adolescent teens at a high school. Which of the following activities should be included?

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: Page Reference: 391

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school-age children, and adolescents.

Question 25

Type: MCSA

A baby was born with flaccid muscle tone, regular respirations with crying, 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: Page Reference: 379

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 26

Type: MCMA

A nurse shows an understanding of growth and development occurring in the first 3 weeks post-conception when discussing:

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 chorionprecursor to the placentaand the amnion, 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: Page Reference: 374-375

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe usual physical development from infancy through adolescence.

Question 27

Type: MCMA

The nurse is confident that a client has met the developmental guidelines for a preschooler when the child:

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: Page Reference: 383-386

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Identify tasks characteristic of different stages of development from infancy through adolescence.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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