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Test Bank For Pediatric Nursing- The Critical Components of Nursing Care 1st Edition by Kathryn Rudd, Diane Kocisko Test Bank

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Test Bank For Pediatric Nursing- The Critical Components of Nursing Care 1st Edition by Kathryn Rudd, Diane Kocisko Test Bank

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  Pediatric Nursing- The Critical Components of Nursing Care 1st Edition by Kathryn Rudd, Diane Kocisko Test Bank

 

Chapter 6: Theoretical Foundations of Growth and DevelopmentChapter 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 nurse’s best response is which of the following? 1. “It’s a simple intelligence test for young children.” 2. “It tells us what a child can do at a particular age.” 3. “It determines a child’s visual acuity.” 4. “It is a test to screen for hearing abnormalities.”
ANS: 2 Feedback1. 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 Feedback1. 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 peers2. Allow time to express feelings3. Use the same language as the adolescent4. Emphasize that confidentiality will be maintained
ANS: 2 Feedback1. 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 months2. 4 months3. 5 months4. 1 year
ANS: 1 Feedback1. Usually occurs at this age2. Too early to sit up3. Too early to sit alone4. Should be sitting before this ageKEY: 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 stranger’s face.3. Reach for the primary care giver. 4. Hold a bottle.
ANS: 1 Feedback1. 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 Feedback1. 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 Feedback1. Does not always occur in this manner2. 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 Feedback1. 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 Feedback1. 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 Feedback1. Does not give a measurement of what 3% to 5% is based on.2. Can have an organic cause3. The NCHS growth charts give a developmental curve for tracking the child’s 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 sandwiches2. Chocolate milk3. Yogurt and bananas4. Chips and low fat dip
ANS: 3 Feedback1. Contains a high level of sugar, which does not aid in growth2. Contains a high level of sugar, which does not aid in growth3. 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 Feedback1. 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 child4. 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. Cephalocaudal3. Differentiation4. None of the above are correct.
ANS: 1 Feedback1. 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 Feedback1. 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 Feedback1. 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 Feedback1. 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 Feedback1. 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 mother’s 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 father’s arms.2. The child cries and refuses to eat with her father.3. The child imitates the father’s actions.4. The child is able to hold the bottle by himself.
ANS: 1 Feedback1. The child is demonstrating being in Piaget’s 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 bike2. Jumping rope3. Jumping off of the bottom stair step4. Walking backward heel to toe
ANS: 3 Feedback1. 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.