1. A nurse is observing all of the following babies in a clinic.

Which baby may be experiencing a

c.

Preschooler-age

d. Adolescent

developmental delay? (Correct) B- Children of all ages are affected by a. A 1-month-old who does not coo b. A 3-month-old who does not crawl c. An 8-month-old who does not walk the separation caused by hospitalization. The manifestations of their reactions to separation differ by age. Separation anxiety usually begins about 6-8 months of age, but is most acute for toddlers. (Correct) D- An infant should be able to sit unsupported by 7 or 9 months. Therefore, further assessment should be made of the 10-monthold. (Eliminate) A- Cooing begins around 2 months of age. (Eliminate) B- Crawling begins around 7 or 8 months of age. (Eliminate) C- At about 9 months, infants begin to cruise and walk around furniture. Category: Health Promotion and Maintenance Category: Health Promotion and Maintenance 4. The nurse is caring for a client who is at risk for 2. A 35-year-old woman, at term, is admitted with a diagnosis of pregnancy-induced hypertension. The priority nursing assessment for the client should be aspiration pneumonia. Which of the following (Eliminate) ANewborns do not

d. A 10-month-old who does not sit

experience separation anxiety. (Eliminate) CWhile preschoolers experience separation

anxiety, it is much more acute in the toddler. (Eliminate) D- While separation from home and parents may be difficult for adolescent; loss of peer-group support may pose a severe

emotional threat.

nursing interventions will help prevent aspiration pneumonia?

a. deep tendon reflexes. b. gravida and para. c. vital signs.

a. Keeping the head of the bed elevated to 45 after delivering enteral feedings b. Providing vigorous pulmonary toileting

d. protein in urine. c. (Correct) C- Baseline vital signs are essential to determine future changes in the clients

immediately after feeding the client Performing mouth care with the client in the supine position d. Auscultating breath sounds as ordered by the primary care provider

condition. The vital signs are the priority because they form the baseline upon which therapy, including medications, will be based. (Eliminate) ANot the priority nursing

(Correct) A- Elevating the head of the client in at least 45 angle or in a sitting position reduces the risk of regurgitation and pulmonary

assessment. (Eliminate) B- Does not relate to the diagnosis of pregnancy-induced hypertension. (Eliminate) D- Not the priority for assessment of pregnancy0induced hypertension.

aspiration. (Eliminate) B- Providing pulmonary toileting after feeding may promote vomiting and aspiration of gastric contents. (Eliminate) CMouth care should be performed with the client

Category: Health Promotion and Maintenance

in a lateral position, not in a supine position, in order to prevent aspiration. (Eliminate) D-

3. One of the effects of hospitalization for children is separation. A nurse should plan to deal with separation anxiety most often when caring for children in which stage?

Frequent auscultation of breath sounds is essential and is an independent nursing action which does not require an order from the physician.

a. Newborn b. Toddler

Category: Health Promotion and Maintenance

b. they may have come into contact with bacteria 5. The nurse is explaining how tuberculosis (TB) is diagnosed. Of the following, which should the nurse tell the client is the definitive diagnosis for TB? c. during birth. newborns dont have tears for about 2 months. d. it is mandated by the law.

a. Arterial blood gas b. Tuberculin skin test c. Supine chest x-ray

(Correct) B- Eye prophylaxis is necessary to protect against exposure to gonorrhea and chlamydia. (Eliminate) A- Birth trauma rather than exposure to light is responsible for edema of the eyelids following delivery. (Eliminate) C-

d. Sputum culture for acid-fast bacillus

(Correct) bacillus

Dare

Sputum the

cultures

for

acid-fast for

While this statement is true, the installation of eye drops at birth is prophylaxis against infection. (Possible) D- Eye prophylaxis is mandated by law, but this response does not provide the parent with an adequate rationale for the mandate.

definitive

diagnosis

tuberculosis. (Eliminate) A- ABG is not a test for tuberculosis. (Eliminate) B- A tuberculin skin test determines if a person has been exposed to the tuberculin bacillus. (Eliminate) C- A supine chest x-ray is not a definitive test for tuberculosis.

Category: Health Promotion and Maintenance Category: Health Promotion and Maintenance 8. The nurse learns from a 17-year-old adolescent 6. The nurse is conducting an in-service class on child development for pediatric staff. The nurse is correct when stating that, according to Erikson, the developmental stage of a 2-year-old child is a. Call her mother immediately a. trust vs. mistrust. b. autonomy vs. shame and doubt. c. initiative vs. guilt. b. Give her pamphlets regarding abstinence c. Find out who her boyfriend is client in the high school health office that she is sexually active. Which of the following interventions is appropriate for the nurse to do next?

d. Find out if condoms are used consistently

d. preoperational thought. (Correct) D- Collecting data is the first step of the (Correct) BAccording to Erikson, the nursing process. Making an assessment of the clients knowledge regarding safe sex and sexually transmitted diseases would be the priority. (Eliminate) A- A trusting nurse-client relationship will be jeopardized if a parent is contacted at this point against the adolescents wishes. (Eliminate) BPamphlets regarding

developmental stage of children aged 1-3 is autonomy vs. shame and doubt. (Eliminate) ATrust vs. mistrust is the developmental stage of infants aged 12-18 months. (Eliminate) C-

Initiative vs. guilt is the developmental stage of children aged 3-6 years. (Possible) D- While preoperational thought is a developmental stage of children aged 2-4, it is Piagets theory, not Eriksons.

abstinence may be helpful later in providing information regarding STDs and pregnancy, but the nurse must first find out what the client knows. (Eliminate) C- The boyfriends name is

Category: Health Promotion and Maintenance

not pertinent.

7. A new father observes the nurse instilling eye drops in his newborns eyes and angrily asks, Why are you doing that? The nurse responds, To protect the eyes because

Category: Health Promotion and Maintenance 9. The nurse is assessing a clients learning. The clients knowledge of foods lowest in both fat and sodium would be accurate if the client selected

a. the exposure to light may cause swelling and irritation.

which of these menus?

a. Tossed salad with blue cheese dressing, cold cuts and vanilla cookies. b. Split pea soup, cheese sandwich, and a banana. c. Cold, baked chicken, lettuce with sliced

tomatoes, and apple sauce. d. Beans and frankfurters, carrot and celery sticks, and a plain cupcake.

(Correct) C- These are all foods low in sodium and fat. (Eliminate) A- The cheese and cold cuts are high in sodium and possibly fat. (Eliminate) B- The pea soup and cheese contain sodium. (Eliminate) D- Beans and frankfurters contain sodium and the frankfurters and cupcake are high in fat.

Category: Health Promotion and Maintenance

10. The nurse can counsel a 16-year-old client that, as compared to previous pre-adolescent years, most normal adolescent boys need

a. more calories but less protein b. more calories and more protein. c. fewer calories but more protein.

d. fewer calories and less protein.

(Correct) B- Adolescent boys need more calories and protein to sustain growth. (Eliminate) AAdolescent boys need high protein for muscle development as well as increased calories. (Eliminate) C&D- Adolescent boys need both more calories and proteins than do pre-

adolescent boys.

Category: Health Promotion and Maintenance