Chapter 6: Theoretical Foundations of Growth and Development My Nursing Test Banks

Chapter 6: Theoretical Foundations of Growth and Development

Multiple Choice

1. The nurse is beginning to administer the Denver II to a small child when his mother says, Can you tell me again what this Denver II is? The nurses best response is which of the following?

1. Its a simple intelligence test for young children.

2. It tells us what a child can do at a particular age.

3. It determines a childs visual acuity.

4. It is a test to screen for hearing abnormalities.

ANS: 2

Feedback
1. The test does not measure intelligence, but focuses on developmental milestones.
2. The test measures the level of development and compares to the standard.
3. The test focuses on cognitive, hearing, visual, and physical skills.
4. The test focuses on cognitive, hearing, visual, and physical skills.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

2. Which of the following characteristics best describes the fine motor skills of a 5-month-old infant?

1. Neat pincer grasp

2. Strong grasp reflex

3. Builds a tower of two cubes

4. Able to grasp objects voluntarily

ANS: 4

Feedback
1. The child is too young for this skill.
2. The child is past this stage of fine motor skill.
3. The child is too young for this skill.
4. This is a normal response for a 5 month old.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

3. Antonio is assessing an adolescent. Identify the top priority.

1. Converse about peers

2. Allow time to express feelings

3. Use the same language as the adolescent

4. Emphasize that confidentiality will be maintained

ANS: 2

Feedback
1. Conversing about peers is not a focus of the assessment.
2. The adolescent needs time to express feelings during the assessment.
3. Adolescents should be spoken to in the same manner as an adult.
4. Confidentiality cannot be maintained if the adolescent speaks of hurting himself/herself or others.

KEY: Content Area: Development | Integrated Processes: Caring | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

4. A new mother is asking about when her baby daughter should be learning to sit. The nurse knows that a baby will sit at approximately which age?

1. 8 months

2. 4 months

3. 5 months

4. 1 year

ANS: 1

Feedback
1. Usually occurs at this age
2. Too early to sit up
3. Too early to sit alone
4. Should be sitting before this age

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

5. A nurse is assessing a 2-and-one-half-month-old infant at the outpatient clinic. The nurse would anticipate that the baby should:

1. Smile when presented with pleasurable stimuli.

2. Cry at seeing a strangers face.

3. Reach for the primary care giver.

4. Hold a bottle.

ANS: 1

Feedback
1. An infant of this age should smile.
2. An infant at this age does not distinguish between stranger and caregiver.
3. An infant at this age is too young to reach for the caregiver.
4. An infant at this age is too young to hold a bottle.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

6. The developmental task that a toddler between the ages of 15 to 30 months is likely to be struggling with is a sense of:

1. Trust.

2. Initiative.

3. Autonomy.

4. Intimacy.

ANS: 3

Feedback
1. The child is past this developmental milestone.
2. The child has yet to reach this stage.
3. The child will demonstrate this behavior.
4. The child has not reached this stage.

KEY: Content Area: Development | Integrated Processes: Teaching /Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

7. Parents of a 2 year old are attempting to toilet train. The nurse has spoken to the family and should encourage which of the following to occur for successful toilet training?

1. Anticipate that the bladder will be trained before the bowel.

2. The child will respond more if the parents are encouraging.

3. Having the child watch an older sibling use the toilet will cause confusion.

4. The child must be forced to sit on the toilet when first learning.

ANS: 2

Feedback
1. Does not always occur in this manner
2. The more encouraging the parent, the higher the success rate.
3. Watching others use the toilet can help the child learn the behavior.
4. The child will resist potty training if forced.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

8. The nurse is attempting to obtain a physical assessment of a 15-month-old child. The nurse knows that the most appropriate approach to performing the physical assessment includes all of the following except:

1. Demonstrating the use of the blood pressure cuff on a teddy bear.

2. Performing the most invasive assessments first.

3. Letting the child exam the nurse first.

4. Taking the blood pressure first, which will allow the child to ease into the full exam.

ANS: 4

Feedback
1. Demonstrating on an object lets the child see what will occur.
2. The invasive procedure will not alarm the child, so the vital signs will not rise quickly.
3. Letting the child examine the nurse allows the child to see what will occur.
4. Taking the blood pressure should not occur until after the heart rate and respiratory rate have normalized.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

9. The purpose of the Tanner Stages is:

1. To identify the five stages of sexual development in adolescents.

2. To identify the cognitive stages of adolescents.

3. To identify the five stages of sexual development for a school-age child.

4. To identify the cognitive development of a school-age child.

ANS: 1

Feedback
1. Identification of sexual development in adolescents is the purpose of the Tanner Stages.
2. Cognitive stages are assessed through other theories.
3. Sexual development does not begin until adolescence, thus the age range is not appropriate.
4. Cognitive stages are assessed through other theories.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

10. Which of the following statements regarding failure to thrive is true?

1. Height or weight is less than 3% to 5% for age on more than one occasion.

2. Failure to thrive is always caused by child abuse or poor parenting.

3. Height or weight falling two major percentile lines on the NCHS growth charts is indicative of failure to thrive.

4. Smoking and alcohol use during pregnancy are linked to failure to thrive.

ANS: 3

Feedback
1. Does not give a measurement of what 3% to 5% is based on.
2. Can have an organic cause
3. The NCHS growth charts give a developmental curve for tracking the childs growth in order for the diagnosis to occur.
4. Failure to thrive occurs after birth.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

11. The mother of a 3 year old with the diagnosis of failure to thrive asks what foods would be good to give her child for nutrition. Identify which foods are healthy choices for the child.

1. Peanut butter and jelly sandwiches

2. Chocolate milk

3. Yogurt and bananas

4. Chips and low fat dip

ANS: 3

Feedback
1. Contains a high level of sugar, which does not aid in growth
2. Contains a high level of sugar, which does not aid in growth
3. The protein from the yogurt and the vitamins/minerals in bananas will aid in a healthy growth pattern for the child.
4. Chips are high in carbohydrates and fat content, which do not aid in growth.

KEY: Content Area: Nutrition | Integrated Processes: Teaching | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

12. A home health nurse is visiting an 18-month-old pediatric patient with the diagnosis of failure to thrive. A priority assessment for the child would be:

1. Head circumference.

2. Height and weight.

3. Abdominal circumference.

4. 1 and 2 should be documented.

ANS: 4

Feedback
1. Head circumference is a priority assessment to make sure the brain is growing at an adequate rate.
2. Height and weight are priority assessments to make sure the child is receiving good nutrition for optimal growth.
3. Does not indicate the growth pattern of a child
4. Head circumference is a priority assessment to make sure the brain is growing at an adequate rate. Height and weight is a priority assessment to make sure the child is receiving good nutrition for optimal growth.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

13. The nurse is assessing a 2-month-old infant. The nurse knows when she sees the child move its head from side-to-side that the child has ___________ control.

1. Proximodistal

2. Cephalocaudal

3. Differentiation

4. None of the above are correct.

ANS: 1

Feedback
1. Movement is demonstrated in side-to-side motions.
2. Movement from head to toe is not demonstrated.
3. The infant is not demonstrating knowledge of the difference between moving the head from side-to-side and moving from head-to-toe.
4. One of the answers is correct.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

14. The nurse is assessing a child who is 3 years old. The Babinski Reflex is assessed and noted to be present. The nurse knows that:

1. This is a normal response to the test.

2. This is an abnormal response to the test and should be further assessed.

3. The reflex is abnormal, but the child will eventually grow out of it.

4. This is normal and should be repeated on both feet.

ANS: 2

Feedback
1. This reflex should not be present in a child of this age.
2. This reflex should not be present after 2 years of life. It presents the need for an in-depth neurological exam.
3. Demonstration of this reflex at this age needs to be further assessed by a care provider.
4. This reflex should not be present at this age. If it is present in one foot, it will be present in the other.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

15. A nursery nurse is assessing a newborn. A normal assessment finding is:

1. The child lifting its head off of the mattress.

2. Head lag is present.

3. Holding hands in an open position.

4. Placing a toy in the mouth.

ANS: 2

Feedback
1. A newborn does not have enough muscle control to lift his or her head off of a mattress.
2. Head lag is normal at this age.
3. At this age, a newborn will not hold their hands in an open position for long periods of time.
4. Placing a toy in the mouth does not occur for several months.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

16. During an assessment, the nurse notes the anterior fontanel of a 5 month old is open. This finding:

1. Is abnormal, and the doctor should be immediately notified.

2. Is abnormal at this age, and a head circumference should be done prior to calling the doctor.

3. Is normal at this age.

4. Is normal and should close by the age of two.

ANS: 3

Feedback
1. This is a normal finding, so the doctor does not need to be notified.
2. This is a normal finding.
3. The normal finding should be documented.
4. This is a normal finding, and the fontanel should close by the age of 18 months.

KEY: Content Area: Assessment | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

17. A mother is concerned that her 8-month-old child does not have any teeth. The best response from the nurse would be:

1. Teeth tend not to come in until around 18 months, so this is normal.

2. I understand your concern about the lack of teeth. I will make sure the doctor addresses your concerns.

3. This is nothing to worry about. Your child is still young, and the teeth will come in when they are ready.

4. Normal tooth eruption occurs by the one year mark. Continue to watch your child, and report to us if teeth have not come in by then.

ANS: 4

Feedback
1. Teeth come at a variety of ages in children.
2. The lack of teeth at this age is normal, and the mother should be reassured that teeth come in at a variety of ages.
3. Stating that there is nothing to worry about is not therapeutic communication by a nurse.
4. This answer identifies the mothers concerns and educates her on when teeth eruption will usually begin.

KEY: Content Area: Assessment | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

18. The nurse is assessing the parent-child interaction of a 6 month old and her teen father. The stage of development for the infant is demonstrated when:

1. The child relaxes and drinks a bottle when in the fathers arms.

2. The child cries and refuses to eat with her father.

3. The child imitates the fathers actions.

4. The child is able to hold the bottle by himself.

ANS: 1

Feedback
1. The child is demonstrating being in Piagets Sensorimotor Stage. The relationship is proven to be positive.
2. The child is demonstrating mistrust with the father when being fed.
3. The child is too young to imitate the actions of the father.
4. The child is too young to hold the bottle by himself, and this does not support an interactive environment with the father.

KEY: Content Area: Development | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

19. The public health nurse is assessing children at the well-child clinic. The nurse is assessing the gross motor skills of a 3 year old. Identify which activity the nurse would expect the child to be successful with.

1. Riding a bike

2. Jumping rope

3. Jumping off of the bottom stair step

4. Walking backward heel to toe

ANS: 3

Feedback
1. A child does not reach this stage until after the age of four.
2. Jumping rope occurs during the school-age years.
3. The child is demonstrating appropriate gross motor skills for his/her age.
4. Walking backward is a skill seen in school-age children.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

20. A school nurse is assessing the interaction of a kindergarten classroom. A normal finding of social interaction at this age would be:

1. Parallel play.

2. Identified sex-role interactions.

3. Pretend play.

4. 2 and 3 would be present in a kindergarten classroom.

ANS: 4

Feedback
1. Parallel play occurs with toddlers.
2. Kindergarten children are able to identify gender roles.
3. Kindergarten children are able to engage in imaginative play.
4. Kindergarten children are able to identify gender roles. Kindergarten children are able to engage in imaginative play.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

21. According to Piagets theory, a normal thought process for an 18 to 24-month-old child would be:

1. A diaper means a diaper changing is going to occur.

2. A rattle should go in the mouth.

3. A loud noise means something bad is going to happen.

4. A thumb is for sucking.

ANS: 1

Feedback
1. The child is able to relate objects to a task.
2. This would occur earlier in the childs life.
3. The child is not old enough to process this information.
4. This would occur earlier in the childs life.

KEY: Content Area: Development | Integrated Processes: Communication/Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

22. A school nurse is teaching a fifth-grade classroom about good eating habits. The nurse knows she should:

1. Allow time for questions and for questions to be asked of the children.

2. Ask the children questions.

3. Demonstrate the eating habits, then allow for questions.

4. Give a quiz at the end to see what the children have learned.

ANS: 1

Feedback
1. Children in this age group are inquisitive and can respond to more complex questions.
2. Reciprocity of communication can be done with this age bracket of students.
3. The children are past the age of needing demonstration to understand good eating habits.
4. A quiz is for older children to check for learning.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

23. A school nurse is working with small groups of high school sophomores to discuss sexually transmitted diseases. The best approach to educate this age range would be:

1. To lecture, then allow for a question and answer period.

2. Having media and handouts to engage the students.

3. Having media and letting the students create information that they feel is pertinent to understand the material.

4. To provide information in handouts.

ANS: 3

Feedback
1. Lecturing may cause teens to not pay attention.
2. Media and handouts are effective, but need to be explained in order to be pertinent for understanding.
3. Letting students exercise creative understanding promotes comprehensive learning.
4. Handouts are not effective unless explained in a pertinent manner to the students.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

24. The student nurse is assessing a 9 month old that has a history of parental neglect. The student notices the child sucks his thumb constantly. According to Freuds theory, this child is in which stage?

1. Id

2. Ego

3. Superego

4. Freuds theory is not applicable for this age range.

ANS: 2

Feedback
1. The child is focusing on calming himself, not on others doing this for him.
2. The infant is demonstrating the ego because the concentration is on soothing the self.
3. The superego is not addressed because the child is focusing on the self.
4. Freuds theory is applicable for this age.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

25. A 13-year-old girl is developing breast buds. She feels that her development is behind most of her friends. The nurse discusses changes that are going to occur during the genital stage and what to expect socially. Identify changes that would be pertinent to this age.

1. Change in friendships

2. Challenge to be independent from parents

3. Struggle with identifying sexuality

4. All of the above are likely to occur at this stage of development.

ANS: 4

Feedback
1. Friendships are likely to change as interests change during this age.
2. This age range challenges parents to seek new boundaries and exhibit independence.
3. Identifying ones sexuality occurs during this time.
4. All are characteristics that are present during this age range.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

26. An 11 month old is being fed by his grandmother. The child appears to have high anxiety and does not feed well. The nurse understands that the child is exhibiting:

1. Trust vs Mistrust.

2. Autonomy vs Shame and Doubt.

3. Initiative vs Guilt.

4. Industry vs Inferiority.

ANS: 1

Feedback
1. The infant has not built a relationship with this grandmother and demonstrates mistrust.
2. The child is not independently feeding.
3. The child is too young to exhibit guilt for his/her actions.
4. The child is too young to exhibit industry because of the lack of physical maturity.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

27. A nurse is assessing a family of five. The nurse knows that the toddler is developing appropriately when the mother states:

1. I cant get her to use the potty when I ask. As soon as I put a diaper back on, she uses it instead.

2. All she wants us to do is feed her.

3. She is always going up to strangers and talking to them.

4. She is very conscientious with her siblings.

ANS: 1

Feedback
1. The child is demonstrating independence. This is a normal finding with a toddler.
2. A toddler should be beyond this state.
3. A toddler demonstrates mistrust toward unfamiliar people.
4. A toddler does not have the cognitive ability for this and is still focused on the self.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

28. The nurse is working with a teen boy who is contemplating having sex with his girlfriend. The nurse knows the teen is struggling with which developmental stage of Eriksonss theory?

1. Industry vs Inferiority

2. Autonomy vs Shame and Doubt

3. Trust vs Mistrust

4. Identity vs Role Confusion

ANS: 4

Feedback
1. This stage occurs earlier in life.
2. The teen is beyond this stage.
3. The teen is beyond this stage.
4. The teen is attempting to identify with his age and the roles that he is supposed to have in a relationship.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

29. Why is it important to provide education about motor vehicle safety to teens?

1. Because this age range makes poor decisions based on lack of experience

2. Because this age range tends to believe nothing will happen to them

3. Because this age range receives a drivers license

4. Because this age range should be as responsible as adults

ANS: 2

Feedback
1. Teens do not feel poor decisions are being made.
2. Teens demonstrate a sense of freedom and independence that makes them believe nothing will cause them harm.
3. Receiving a drivers license requires safety, but is not the main reason for teens to have motor vehicle safety education.
4. A teenage brain does not have the capability of understanding circumstances like an adult.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

30. A nursing student is studying Kohlbergs social-moral development. He knows that a child that attempts to do well on a spelling test for approval is in which stage?

1. Reward and punishment

2. Stage three

3. Stage six

4. Post-conventional Morality

ANS: 2

Feedback
1. A child does not link a reward for doing well in Kohlbergs theory at this stage.
2. This stage identifies the success of a child as related to approval from adults.
3. A child does not link a reward for doing well in Kohlbergs theory at this stage.
4. A child does not link a reward for doing well in Kohlbergs theory at this stage.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

31. An 8-year-old boy, who was adopted, has a history of neglect and physical abuse. After living in the adoptive home for one year, the child is exhibiting similar speech patterns as the adoptive father. This is knows as:

1. Nurture.

2. Nature.

3. Moral development.

4. Cognitive development.

ANS: 1

Feedback
1. The child is in an environment that is supportive, and the child is demonstrating positive behavior patterns.
2. The child was not born with the speech patterns of the adoptive father.
3. The child may be developing moral values, but the speech patterns are a mimic of positive behavior.
4. The child may be developing cognitively, but the speech pattern is a mimic of positive behavior.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

32. Identify the family type that has a father, daughter, and stepmother:

1. Blended.

2. Nuclear.

3. Traditional Nuclear family.

4. Bi-nuclear family.

ANS: 1

Feedback
1. A blended family has a stepparent.
2. The family does not consist of all the parents being biological to the child.
3. The family does not have a grandparent living in the home.
4. The home does not have extended family of either parent.

KEY: Content Area: Family Structure | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity| Cognitive Level: Comprehension | REF: Chapter 6 | Type: Multiple Choice

33. A nurse is assessing a child who appears to be very active, highly anxious, and lacks attention to detail. The nurse asks the child to sit still for the taking of the heart rate. If using Banduras theory, the nurse will need to:

1. Attempt to do the assessment on someone else first so the child can watch and learn.

2. Take the heart rate as quickly as possible.

3. Observe the childs activity level and not document the heart rate.

4. Allow the child to be active and discuss what a heart rate means.

ANS: 1

Feedback
1. Demonstration allows the child to decrease his/her anxiety level.
2. Banduras approach is to calm and reduce stress for the child.
3. The heart rate is required and allowing the child to continue playing will not decrease anxiety and activity level.
4. Teaching the child about heart rate is important, but until the child is focused, the teaching will not be successful.

KEY: Content Area: Development | Integrated Processes: Communication/Documentation | Client Need: Psychosocial Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

34. A mother has given birth to her baby at 28 weeks gestation. The nurse knows that a premature birth:

1. Causes future assessments to be based on the adjust age, not the chronological age.

2. Does not cause a delay in growth and development.

3. Occurs rarely and will not affect future assessments.

4. Will reach developmental milestones at the same time as other full-term newborns.

ANS: 1

Feedback
1. An age adjustment must be done to adequately assess the development of the infant.
2. A delay in growth and development occurs because the brains synapses are not fully developed at 28 weeks gestation.
3. Future assessments will be impacted because of the lack of brain development at 28 weeks gestation.
4. A delay in growth and development occurs because the brains synapses are not fully developed at 28 weeks gestation.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

35. At a well-baby checkup, the nurse is assessing a former 32-week, premature infant. The chronological age of the infant is 6 months, so the nurse knows that during the assessment, the infant should be meeting the milestones of a(n):

1. 8 month old.

2. 4 month old.

3. 6 month old.

4. 3 month old.

ANS: 2

Feedback
1. Too old
2. Correct
3. Needs adjustment to the age due to prematurity
4. Too young

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

36. A home care nurse witnesses a mother yelling at her 2 year old to quit crying because it gives everyone a headache. The home care nurse should:

1. Make sure the child is safe, remove the mother from the situation, and contact social services and the police for help.

2. Ask the mother to stop yelling because a 2 year old cannot understand that crying is no good.

3. Explain to the mother that a 2 year old needs to cry to be understood.

4. Contact the police to investigate for child abuse.

ANS: 1

Feedback
1. The safety of the child is the most important factor. Removing the child and getting help for the mother are important in maintaining the childs safety.
2. Speaking to the mother at this point may work, but the nurse needs to be concerned for the childs safety. Further abuse may occur when no one else is present.
3. Speaking to the mother at this point may work, but the nurse needs to be concerned for the childs safety. Further abuse may occur when no one else is present.
4. The mother needs interventions to help learn to cope with the situation. Only using law enforcement does not help the mother learn parenting techniques.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

37. A nurse is reviewing the results of a lead test with a teen mother. The mother asks how the child was exposed to lead. The best response would be:

1. Lead is in the everyday environment. Some people are more susceptible than others.

2. Lead is in many of the foods we eat, so it is important to eat fresh vegetables and fruits because these foods have a lower lead level.

3. Lead can be found in the paint within your house or on some old toys that had lead-based paint.

4. You need to make sure that your child is kept away from lead because it can cause brain damage.

ANS: 3

Feedback
1. Lead poisoning can happen to anyone.
2. Lead is mostly found in objects that cannot be consumed.
3. Lead-based paint causes the highest number of lead exposure.
4. Lead toxicity can cause brain damage, but the most important point is to teach the parent where lead can be found.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

38. Sleep deprivation in a child can lead to:

1. Poor school performance.

2. Hyperactivity.

3. Irritability.

4. All of the above.

ANS: 4

Feedback
1. Lack of sleep can cause inattentiveness in the classroom. This is not the only correct answer.
2. Lack of sleep can cause the child to be more active. This is not the only correct answer.
3. Lack of sleep can cause the child to be unable to tolerate certain situations. This is not the only correct answer.
4. All of the choices are correct answers.

KEY: Content Area: Sleep Patterns | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 6 | Type: Multiple Choice

39. When assessing with Maslows Hierarchy of Need, the nurse knows that self-actualization can only occur if:

1. All the other levels have been met.

2. The first stage of the needs chart is met.

3. Parental involvement is present.

4. The child has a certain level of self-esteem.

ANS: 1

Feedback
1. All levels must be met to achieve self-actualization.
2. Self- actualization is the final stage of the hierarchy.
3. A person must reach this level with people outside of their family.
4. A child has a level of self-esteem no matter what the situation.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Analysis | REF: Chapter 6 | Type: Multiple Choice

40. A safe environment for a school-aged child would include:

1. Dressers being pulled away from a wall.

2. A helmet when rollerblading.

3. A safety lock on a cupboard with cleaning supplies.

4. All are safety issues for a school-aged child

ANS: 4

Feedback
1. Positioning the dresser away from the wall allows for less of a chance for tipping, but this is not the only correct answer.
2. A helmet is needed for any activity with wheels, but this is not the only correct answer.
3. A safety lock is needed to keep hazardous materials out of reach, but this is not the only correct answer.
4. Correct. All choices are safety issues for children.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

41. The school nurse is discussing safety hazards with a group of parents. The nurse states that it is important to:

1. Lock everything you do not want your child to get to up in a safe place.

2. To place the poison control number and emergency numbers near a phone, or program it into your cell phone.

3. Remind a child to ride on the left side of the road toward traffic when on a bike.

4. Allow a child to use the stove once they are five feet tall.

ANS: 2

Feedback
1. A school-age child can unlock cupboards.
2. Having easy access to emergency numbers will aid in emergency situations.
3. The child should ride on the right side of the road with traffic on a bike.
4. Height does not influence whether or not a child should use a stove.

KEY: Content Area: Safety | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Choice

Multiple Response

42. A nurse at a teen outreach center for pregnant mothers is discussing dental care with patients. Pertinent information for the nurse to teach about would be: (Select all that apply.)

1. Cleaning the infants teeth with cool, wet washcloths at least every day.

2. Bottles can be given in order for the infant to fall asleep and will not cause damage to the teeth.

3. Juice should not be provided because it increases tooth decay.

4. Providing teething rings can help reduce the pain of teething.

5. Brushing of teeth should only occur every few days.

ANS: 1, 3, 4

Feedback
1. A wet washcloth is gentle enough for an infants teeth.
2. Bottles at bedtime increase the risk of dental decay in infants.
3. Juice can cause tooth decay.
4. Teething rings can help reduce pain.
5. A brush may be too harsh for an infants teeth.

KEY: Content Area: Dental Care | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Response

43. The school nurse is helping in a classroom of 7 and 8 year olds on a rainy day. The nurse knows which types of games would be fun for this age range? Select all that apply.

1. Playing a board game

2. Playing a video game

3. Playing jump rope

4. Making crafts

5. Making a friendship bracelet

ANS: 1, 4, 5

Feedback
1. A child of this age understands and participates in board games.
2. A video game can be overwhelming for a child of this age range.
3. Jumping rope may not be an acquired skill at this age and is not a game to be played in the classroom due to safety concerns.
4. Making crafts is appropriate for this age.
5. Friendships become important at this age and making the bracelets is appropriate.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Response

44. During the preoperational stage, a 6 year old would be expected to: (Select all that apply.)

1. Gather more language skills.

2. Use crayons to draw pictures about being mad.

3. Think real things are fantasy.

4. Understand time.

5. Remember events from the recent past.

ANS: 1, 2, 5

Feedback
1. The child is learning new words and meanings rapidly at this time.
2. The child is learning to channel emotions into drawings.
3. The child is past this point and realizes what is real.
4. The child is too young to begin to understand time.
5. The child is able to remember events that have occurred recently.

KEY: Content Area: Development | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 6  | Type: Multiple Response

45. Factors that can impact the intrauterine growth of a fetus are: (Select all that apply.)

1. The mothers nutrition.

2. Maternal smoking.

3. The mothers employment.

4. The fathers employment.

5. Prescription drugs.

ANS: 1, 2, 5

Feedback
1. The mothers calorie, vitamin, and mineral intake all influence the fetuss growth.
2. Smoking inhibits the growth of the fetus due to lack of oxygen.
3. Employment is not a factor in growth.
4. Employment is not a factor in growth.
5. Certain medications decrease nutrition and oxygen to the fetus during development.

KEY: Content Area: Growth and Development | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 6 | Type: Multiple Response

True/False

46. Separation anxiety is a normal development in a preschooler.

ANS: F

Feedback
1. Separation anxiety is seen in toddlers. Preschoolers fear the dark, being left alone, ghosts, and mutilation.
2. Separation anxiety is seen in toddlers. Preschoolers fear the dark, being left alone, ghosts, and mutilation.

KEY: Content Area: Development | Integrated Processes: Nursing Process | Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | REF: Chapter 6 | Type: True/False

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