NCLEX – Flashcard
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A 14-year-old girl in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the girl's need to achieve what developmental milestone?
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identity
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Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is
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intimacy versus isolation
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Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?
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sole creases covering entire foot
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A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which information would the nurse include when teaching the mother about neonatal strabismus?
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neonates commonly lack eye muscle coordination
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When discussing an infant's motor skill development with the mother, the nurse should explain that by age 7 months, an infant most likely will be able to
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sit alone using the hands for support
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Which suggestion would be most helpful to the parents of a 2-year-old child when managing separation anxiety during hospitalization?
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Bring the childs toys, blankets, or other familiar objects from home
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Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first
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Examine fontanels and sutures
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While performing an assessment, a nurse observes a 6-month-old infant transferring an object from one hand to another and reaching for the nurse's stethoscope. The mother tells the nurse this is new behavior and asks if it is normal. The nurses educates the mother about growth and development parameters for a 6-month-old infant. She responds by stating
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This is normal behavior for a 6 month old infant
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The nurse is performing an assessment on a client with a history of a dysfunctional family. Which findings should the nurse anticipate? Select all that apply
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Abuse and neglect Unhealthy personal boundaries
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A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the mother about infant nutritional needs. Which statement by the mother during the current visit indicates effective teaching?
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"I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated."
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A mother asks the nurse why her 12-month-old baby gets otitis media more frequently than her 10-year-old son. What should the nurse tell her?
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The baby's eustachian tubes are shorter and lie more horizontally.
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A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes him to the neonatal intensive care unit (NICU), places him on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to
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Enhancing bonding by pointing out the neonate's features
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While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains about the neonate's need for gavage feeding at this time instead of the mother's plan for bottle feeding. What should the nurse include as the rationale for this feeding plan
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The neonate has difficulty coordinating sucking, swallowing, and breathing
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A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother
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Birth weight doubles by age 6 months
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The nurse in the emergency department is caring for a 3-year-old child with a fractured humerus. The child is crying and screaming, "I hate you!" Which action would be most appropriate
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Reassure the parents that this a normal behavior under the circumstances.
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Which adolescent would the nurse determine needs further evaluation
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a young adolescent boy who restricts his food and fluid intake to be able to box in a lower weight class
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An adolescent typically achieves formal operational thought, Piaget's final stage of cognitive development. Which cognitive abilities are achieved during this stage? Select all that apply
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Flexibility Complex deductive reasoning Abstract thinking
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After teaching a community class to new parents, the nurse evaluates client understanding of strategies to prevent sudden infant death syndrome (SIDS). Which of the following statements indicates appropriate understanding
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"I will place my baby in a supine position for sleep during the first year."
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A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate?
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Showing trust in the child's ability to cooperate even with an unpleasant procedure
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A multiparous client gives birth to dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. What is the most appropriate goal to include in the plan of care for the parents while the twins are hospitalized
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Participate in care of the twins as much as possible.
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When assessing speech development, which child should the nurse refer for further examination?
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an 18 month old who only says "no"
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6-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery
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Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.
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On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the parent tells the nurse that a toddler answers "No!" and is difficult to manage. After discussing this further with the parent, the nurse explains that the child's behavior is most likely the result of which factor
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expression of individuality
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A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options
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Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion
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The mother of a 4-year-old child is concerned about her child's masturbating. The nurse should tell the mother
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Masturbation is normal at that age
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Anticipating that a 3-year-old child in traction will have need for diversion, what should the nurse offer the child
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hand puppets
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A nurse is caring for a 9-year-old child who is shy and fearful. The nurse asks the child a question, but the child does not answer immediately. What is the best approach by the nurse to develop a therapeutic relationship with the child
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Remain silent after asking a question
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A 13-year-old girl is being evaluated for possible Crohn's disease. She is about to undergo a colonoscopy with biopsy. While teaching about the diagnosis, the nurse is asked whether the client's delayed puberty is a result of the disease process. Which of the following is the nurse's best response
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"No definitive diagnosis has been made yet; it's best to wait until testing is complete."
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When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include
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delayed gastric emptying
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A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that she can expect to feel the fetus move at which time
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Between 16 and 22 weeks' gestation
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Which characteristic should the nurse include in the teaching plan for a multiparous client after giving birth to a neonate diagnosed with trisomy 13
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polydactyly
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A 4-year-old child continues to come to the nurses' station after being told children are not allowed there. What behavior is the child exhibiting
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attention seeking behavior
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After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal?
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encourage self care skills in the child
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To meet the developmental needs of an 8-year-old child who is confined to home with osteomyelitis, what goal should the nurse include in the care plan
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Encourage the child to communicate with school mates
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Parents ask the nurse for advice about handling their 2-year-old's negativism. What is the best recommendation
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set realistic limits for the child and be sure to stick to them
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An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling" him. Which response would be most appropriate
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hold him as much as you want to hold him
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A 24-year-old primipara who has given birth to a healthy neonate plans to bottle-feed her neonate. What information regarding normal weight gain should the nurse include in the teaching plan
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gaining 30 g/day is a normal weight gain pattern
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An 18-month-old child is admitted to the pediatric unit. Which of the following can the nurse do to reduce the stress on the client during this hospitalization
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encourage the clients caregivers to be with the client as much as possible
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A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful?
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Encourage the client to see, touch, and hold the dead neonate
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Which response would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate delivered at 25 weeks dies while the mother is present?
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"You can stay with your baby as long as you want and say anything you want."
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A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior?
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"Reviewing your losses is a way to help you work through your grief and loss."
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The nurse is encouraging an unlicensed assistive personnel (UAP) to interact with a dying client and family. The nurse should help the UAP understand that:
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when health care personnel do not understand their own feelings about death and dying, they often avoid the client.
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A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client?
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anticipatory grieving
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A client states that her "life has gone down the tubes" since her divorce 6 months ago. Then, after she lost her job and apartment, she took an overdose of barbiturates so she "could go to sleep and never wake up." Which statement by the nurse should be made first?
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"I know you took an overdose of barbiturates. Are you thinking of suicide now?"
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A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He is fine except for this irrational belief that we will remarry." When collaborating with the health care provider (HCP) about a plan of care, which intervention would be most effective for the client at this time?
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referral to an outpatient therapist
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A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs?
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"It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home.
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A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response?
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Approach the client and ask if there are questions about the condition.
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A client undergoing a mastectomy says, "I've been a basket case just thinking of what implications this has for my family." How should the nurse respond?
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"This is a very difficult adjustment period for you and your family.
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A nurse is caring for a 5-year-old boy with end-stage acquired immunodeficiency syndrome (AIDS). The child confides that he is ready to go to heaven and see his grandpa. The nurse knows that the child's parents aren't comfortable with the idea of discontinuing treatment. What should she do?
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Talk with the parents about the dying process and make them aware of what their child has confided.
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Parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate?
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"At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it.
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Which child should the nurse identify as being most at risk for an episode of major depression?
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a 14-year-old female who recently moved to a new school after her parents' divorce
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A terminally ill client's husband tells the nurse, "I wish we had taken that trip to Europe last year. We just kept putting it off, and now I am furious that we did not go." The nurse interprets the husband's statement as indicating which stage of adaptation to dying?
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anger
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At an emergency shelter, an earthquake victim tells the nurse that he is going to spend the night in his own bed at home. Which defense mechanism is the client exhibiting?
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denial
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Which nursing action is most appropriate to include in the plan of care for a dying child to meet the child's emotional needs during the last days of life?
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Answer the child's questions about illness and death honestly
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A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." The nurse should:
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allow the client to see and hold the baby for as long as she desires
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The physician has indicated that a client has a poor prognosis for recovery, and the family is very concerned. How would the nurse best support the family?
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Attune to their grieving, explain what is happening, and encourage involvement in the care.
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A nurse is working with a dying client and the client's family. Which communication technique is most important to use?
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Use active listening and silence when communicating.
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A client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which responses by the nurse are appropriate? Select all that apply.
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"Let's talk about your mother's illness and how it will progress." "You sound like you have some questions about your mother dying. How can I help?" "Tell me how you're feeling about your mother dying."
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Which nursing activity supports the principles of palliative care for a dying infant and his family?
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Creating a therapeutic, homelike environment for the infant and his family
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A client with end-stage pancreatic cancer has decided to terminate medical intervention. What should a nurse anticipate when consulting with palliative care?
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Referral for bereavement counseling
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A nurse is caring for a 5-year-old child who's in the terminal stages of cancer. Which statements are true? Select all that apply
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The death of a child may have long-term disruptive effects on the family. The child does not fully understand the concept of death. The dying child may become clingy and act like a toddler. The parents may be at different stages in dealing with the child's death.
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The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What is the use of living? My time is running out." What is the nurse's best response?
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"You are in a lot of pain. What are you feeling?"
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The parents of a 3-month-old infant have been told that their infant has died of sudden infant death syndrome. Which intervention is most important to include in the plan of care to assist the parents with their grieving process?
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Provide an opportunity for them to see the infant.
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On entering the room of a client who has undergone a dilatation and curettage (D;C;) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate?
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"I am truly sorry you lost your baby."
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A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which outcome is most appropriate initially?
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The client will discuss her feelings related to her losses.
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The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?
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"You're very concerned when you think about how this will change your life."
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A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse?
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I would like to sit with you for a while and talk about your child and family."
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A client is brought to the emergency department dead on arrival (DOA) from a gunshot wound. The client's family arrives and is escorted to a private area. A multidisciplinary team composed of a physician, nurse, and social worker interacts with the family. All members work together to complete the following tasks. Which are the priority nursing responsibilities? Select all that apply.
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Providing therapeutic touch and support as needed Caring for body organs which are appropriate for transplantation Escorting the client's family for viewing of the body
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A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond?
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"I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again."
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A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?
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The chaplain, because his educational background includes strategies for handling grief
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While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief?
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shock
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The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I am so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which intervention is most helpful?
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Refer her to a group for survivors of suicide.
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A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and to be hostile. The nurse interprets this behavior as indicative of which response?
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a stage of grief reaction
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A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should:
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explore the nurse's own feelings about the issues of anencephaly and organ donation
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A 19-year-old male with cystic fibrosis (CF) is hospitalized for a serious lung infection and is in need of a lung transplant. However, he has a rare blood type that complicates the process of obtaining a donor organ. He has also been diagnosed with bipolar disorder and treated successfully since mid-adolescence with medication and therapy. The client requests to see a chaplain to help him make plans for a funeral and donation of his body to science after death. How should the nurse interpret the client's request?
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It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff.
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A cancer survivor feels guilty when attending a cancer support group meeting. The nurse can help the client manage feelings of guilt by pointing out that
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this is a normal reaction when surviving a life-threatening experience
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A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply
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Provide an early opportunity for the couple to see their child if they desire. Answer the parents' questions accurately. Offer to stay with the grieving parents.
