Chapter 11: Conception Through Adolescence Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. A client in her second trimester of pregnancy comes to the prenatal clinic for a check-up. Which of the following is the most important for the nurse to assess in caring for a woman at this stage of her pregnancy?

a.

Detection of fetal movement

b.

Observation that the uterus is below the symphysis pubis

c.

Confirmation of the desire to breast- or bottle-feed

d.

Determination of the presence of morning sickness

ANS: a

a. During the second trimester, between 16 and 20 weeks gestation, the mother begins to feel fetal movement.

b. During the second trimester, the uterus should be above the level of the symphysis pubis.

c. Confirmation of the desire to breast- or bottle-feed is more likely to take place during the third trimester.

d. Morning sickness is most likely to occur during the first trimester.

REF: Text Reference: p. 175

2. A 6-month-old child is brought to the clinic for a well-baby examination. The nurse conducting the examination is checking the babys reflexes. Which one of the following newborn reflexes should the nurse be able to elicit at this visit?

a.

Babinski

b.

Extrusion

c.

Startle

d.

Moro

ANS: a

a. The Babinski reflex is a normal reflex found in a 6-month-old infant.

b. Before age 6 months, the extrusion reflex causes food to be pushed out of the mouth. It is normally present from birth to 4 months.

c. The startle reflex is seen in the newborn.

d. The Moro reflex is seen in the newborn.

REF: Text Reference: p. 178

3. The nurse is aware of the expected growth and development of the infant to determine whether any abnormalities are present. In evaluating the infants physical status and growth, the nurse expects to find that the:

a.

Birth height increases 1 inch each month for the first 6 months.

b.

Anterior fontanel closes 4 to 8 weeks after birth.

c.

Chest circumference is larger than head circumference at 12 months.

d.

Birth weight triples by 6 months.

ANS: a

a. Height increases an average of 1 inch during each of the first 6 months and 1/2 inch during the next 6 months.

b. The anterior fontanel closes at about 12 to 18 months.

c. The head and chest circumference are equal at age 1 year.

d. Birth weight doubles in approximately 5 months and triples by 12 months.

REF: Text Reference: p. 180

4. A 6-month-old is seen for a well-baby examination. On evaluation of the infants developmental status, the nurse expects that the child at this age will be:

a.

Assuming a sitting position independently

b.

Pulling self to a standing position

c.

Rolling completely over

d.

Creeping on all four extremities

ANS: c

c. A 6-month-old infant is able to roll over.

a. A 9-month-old infant is able to attain a sitting position independently.

b. A 9-month-old infant is able to pull self to a standing position.

d. A 9-month-old infant is able to creep on all four extremities.

REF: Text Reference: p. 183

5. The nurse works in a pediatric medical day care center. An important aspect of his role is to determine whether children are achieving developmental milestones. For a 2-year-old child, the cognitive development is characterized by:

a.

Using short sentences to express independence

b.

Initiating play with other children

c.

Recognizing right and wrong

d.

Having a vocabulary of at least 1000 words

ANS: a

a. A 2-year-old child uses short sentences to express independence and control.

b. The 2-year-old may engage in solitary play and begin to participate in parallel play. The preschool child may initiate play with other children.

c. A 2-year-old child does not understand the concepts of right and wrong.

d. A 2-year-old child has a vocabulary of up to 300 words.

REF: Text Reference: p. 190

6. An 18-month-old child is admitted for a hernia procedure. In planning nursing care for this child, the nurse should know the predominant developmental characteristic of children this age?

a.

Imaginary playmates

b.

Parallel play

c.

Peer pressure

d.

Mutilation anxiety

ANS: b

b. During toddlerhood, the child begins to participate in parallel play, which is playing beside rather than with another child.

a. The preschool child may have imaginary playmates.

c. Peer pressure is seen with the school-age child.

d. A fear of the preschool child is bodily harm.

REF: Text Reference: p. 190

7. A 5-year-old boy is admitted to the surgical center to have his tonsils removed. In working with children of this age, the nurse plans to:

a.

Allow the child to take responsibility for his own preoperative hygienic care

b.

Leave him alone to relax before the procedure

c.

Allow him to handle and look at the equipment when taking his blood pressure

d.

Provide magazines and puzzles for diversion

ANS: c

c. Preschool children may cooperate if they are allowed to manipulate the equipment.

a. A preschool child is unable to take responsibility for his or her own preoperative hygienic care.

b. Leaving the preschooler alone may increase the childs anxiety.

d. Magazines and puzzles would be more appropriate activities for the older child. The preschool child likes to engage in pretend play by using the imagination and imitating adult behavior.

REF: Text Reference: p. 194

8. A parent of a 3-year-old states that she is concerned because he was potty trained long before hospitalization but now refuses to use the toilet. What is the best response by the nurse?

a.

You may need to include the staff in using discipline because children easily lose the ability to be toilet trained during hospitalization.

b.

This common behavior is expressed when the child is stressed or anxious.

c.

Your son was probably not ready to be potty trained, and you may want to continue the training for the next 6 months.

d.

Your son is probably feeling neglected, and you should make an effort to spend more time with him.

ANS: b

b. During times of stress or illness, preschoolers may revert to bed-wetting or thumb-sucking and want the parent to feed, dress, and hold them. Reassuring the parent that this is normal coping behavior may help alleviate their concern.

a. Disciplining the child would not be a correct response. The child should be provided with experiences he or she can master. Such successes help the child to return to the prior level of independent functioning

c. Reverting to a prior level of functioning, such as a child who was potty trained now refusing to use the toilet, does not indicate the child was unready to be potty trained. The behavior more likely demonstrates that the child is experiencing stress, and this is a coping behavior.

d. Reverting to a prior level of functioning, such as a child who was potty trained now refusing to use the toilet, does not indicate the child is feeling neglected. The behavior demonstrates that the child is experiencing stress, and this is a coping behavior.

REF: Text Reference: p. 194

9. A 41/2-year-old is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort?

a.

Please try to not move your leg, and that will make it feel better.

b.

Ill give you a shot that will help take the pain away.

c.

Its OK to cry. Ill get you something to make you feel better. Would you like to hold your favorite doll?

d.

Would you like to hold this needle and tell me where you want me to give you your shot?

ANS: c

c. This response by the nurse informs the child what he or she can do, and involves an age-appropriate familiar toy to provide comfort.

a. Telling the child not to move when in pain is unlikely to be effective. A preschool child may have difficulty in understanding the request.

b. Telling the child he or she is going to get a shot may increase the anxiety, as the child fears bodily harm.

d. It would not be appropriate to give a child a needle. Instead, the child could hold a cotton ball or band-aid, or manipulate play medical equipment. If a child is allowed to determine the site for administration of an injection, specific sites should be offered as choices. However, the nurse must avoid allowing procrastination by the child.

REF: Text Reference: p. 193, Text Reference: p. 194

10. The nurse is going to teach the parents of a 3-month-old about basic infant safety. The nurse should emphasize:

a.

Placing gates or fences at stairways

b.

Keeping bathroom doors closed

c.

Giving large teething biscuits

d.

Removing bibs at bedtime

ANS: d

d. Bibs should be removed at bedtime to avoid suffocation.

a. Placing gates or fences at stairways is an appropriate safety measure to prevent falls of the 8- to 12-month-old infant.

b. Keeping bathroom doors closed is an appropriate safety measure to prevent drowning of the 8- to 12-month-old infant.

c. Caution should be exercised when giving teething biscuits to a 4- to 7-month-old infant because large chunks may be broken off and aspirated. Teething biscuits are typically not given to a 3-month-old.

REF: Text Reference: p. 183

11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse informs the parents that the child will be able to:

a.

Say Da-da

b.

Smile responsively

c.

Differentiate a stranger

d.

Play peek-a-boo games

ANS: b

b. Two- and 3-month-old infants begin to smile responsively rather than reflexively.

a. By age 1 year, infants have two- or three-word vocabularies such as Da-da.

c. By 8 months, most infants can differentiate a stranger from a familiar person.

d. By 9 months, infants play simple social games such as patty-cake and peek-a-boo.

REF: Text Reference: p. 181

12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing. The nurse responds correctly by telling the client that:

a.

The organ systems are beginning to develop.

b.

Fingers and toes are differentiated clearly.

c.

The sex of the baby can be determined.

d.

Fine hair covers the body.

ANS: a

a. During the first trimester of pregnancy, the organ systems are beginning to develop.

b. During the second trimester of pregnancy, fingers and toes are differentiated.

c. During the second trimester of pregnancy, the sex of the fetus can be determined.

d. During the second trimester of pregnancy, fine hair, called lanugo, covers most of the body of the fetus.

REF: Text Reference: p. 174

13. The nurse assists the family of a 9-year-old with nutritional information. A recommended after-school snack for a child of this age is:

a.

Bite-size candy

b.

Thick milk shakes

c.

Potato chips

d.

Plain popcorn

ANS: d

d. Plain popcorn, fresh fruit, raw vegetables, cheese, skim-milk pudding, and hot chocolate are appropriate after-school snacks.

a. Candy bars should be discouraged as a snack because they are high in fat and calories, are low in nutrition, and are cariogenic.

b. Thick milk shakes would be high in fat and calories; better food choices are available for after-school snacks.

c. Potato chips should be discouraged as a snack because they are high in fat and low in nutritional value.

REF: Text Reference: p. 204

14. The nurse in the elementary school works closely with the students and is responsible for evaluating each childs overall physical development. During the school-aged years, the nurse anticipates that:

a.

The child will grow an average of 1 to 2 inches per year.

b.

The childs weight will almost triple.

c.

Few physical differences will be apparent among children at the end of middle childhood.

d.

Body fat will gradually increase, which contributes to the childs heavier appearance.

ANS: a

a. During the school-aged years, the child will grow an average of 1 to 2 inches per year.

b. During the school-aged years, the child will gain an average of 4 to 7 pounds a year. Many children double, not triple, their weight during these middle childhood years.

c. Growth accelerates at different times for different children. Many physical differences are apparent among children at the end of middle childhood.

d. The school-age child appears slimmer as a result of changes in fat distribution and thickness.

REF: Text Reference: p. 198

15. A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization?

a.

Crayons and a book to color in

b.

A 1000-piece puzzle to complete

c.

A cassette player with soothing tapes to listen to

d.

A Nerf football to throw around the room

ANS: a

a. Providing a 6-year-old with crayons and a book to color in would be an age-appropriate activity to help the child with the crisis of hospitalization. Painting, drawing, playing computer games, and modeling allow children to practice and improve newly refined skills.

b. A 1000-piece puzzle would be too much for a 6-year-old to complete.

c. A cassette player with soothing tapes would not be an age-appropriate activity for a 6-year-old.

d. Throwing a Nerf football around the room may not be appropriate for a hospitalized child with asthma.

REF: Text Reference: p. 198

16. Which one of the following is correct regarding the preadolescence developmental stage?

a.

It appears 2 years earlier in boys than in girls.

b.

Intimate feelings about school and friends are confided in the parents.

c.

Interest in the opposite sex is still not a factor for this age group.

d.

It signals the development of secondary sex characteristics.

ANS: d

d. The preadolescence developmental stage (puberty) signals the development of secondary sex characteristics.

a. Physical changes often begin 2 years earlier in girls than in boys.

b. Preadolescents usually develop best friends with whom they share intimate feelings.

c. New interest in the opposite sex develops in the preadolescence developmental stage.

REF: Text Reference: p. 205

17. The nurse, aware that suicide is a serious potential in the adolescent age group, is teaching parents about probable warning signs that a teenager is considering suicide and tells them to be alert to:

a.

An increase in appetite

b.

A sudden interest in school activities

c.

A unexplained increase in sleepiness

d.

Verbalization of thoughts about death and personal harm

ANS: d

d. A warning sign that a teenager is considering suicide includes verbalization of suicidal thoughts.

a. Appetite disturbances, usually a decrease in appetite, may be a warning sign that a teenager is considering suicide.

b. A decrease in school performance and loss of initiative are possible warning signs that a teenager is considering suicide.

c. Sleep disturbances, such as the inability to sleep, are a warning sign for suicide.

REF: Text Reference: p. 210

18. A 14-year-old girl is visiting the county health center for birth control help. Which of the following is the most appropriate question the nurse could ask her to obtain the most information?

a.

Have you told your parents that you are sexually active?

b.

Are any of your friends participating in sexual behaviors?

c.

What can you tell me about your past sexual activities?

d.

Have you been protecting yourself with safe sex measures?

ANS: c

c. The nurse can be proactive by using the interview process and open-ended questions, such as this one, to identify risk factors in the adolescent. Once identified, the risk factors should lead to strategies for prevention.

a. This question does not obtain the most information.

b. This question does not address the individual and does not obtain the most information about the health behaviors of the client.

d. This question may be answered with a yes or no response and therefore does not obtain the most information.

DIF: 11 REF: Text Reference: p. 205

19. The neonate in the delivery room demonstrates a heart rate less than 100/beats per minute, a slow, irregular respiratory effort, some flexion of the extremities, a vigorous cry, and a pink trunk with bluish hands and feet. According this observation, the nurse determines that the neonates Apgar score is:

a.

4

b.

6

c.

8

d.

10

ANS: b

b. Heart rate is scored as 1; respiratory effort, 1; muscle tone, 1; reflex irritability, 2; and color, 1; for a total Apgar score of 6.

a. The neonates Apgar score is not d.

c. The neonates Apgar score is not 8.

d. The neonates Apgar score is not 10.

REF: Text Reference: p. 176

20. In the nursery, the nurse is taking the newborns vital signs. The nurse compares the newborns measurements with the expected values for this age group which are:

a.

HR, 140; BP, 72/44; R, 46

b.

HR, 100; BP, 90/50; R, 24

c.

HR, 90; BP, 100/60; R, 20

d.

HR, 80; BP, 100/70; R, 16

ANS: a

a. The expected values for the newborns vital signs are heart rate, 120- to 160 beats per minute; blood pressure, 74/46 mm Hg, and respiratory rate 30 to 50 breaths per minute. This option demonstrates values within the normal range.

b. In this option, the heart rate and respiratory rates are too low, and the blood pressure is too high for a newborn. These would be normal vital signs for a toddler.

c. In this option, the heart rate and respiratory rate is too low, and the blood pressure is too high for a newborn. These vital signs are more consistent with the normal range for a preschooler.

d. In this option, the heart rate and respiratory rate are too low, and the blood pressure is too high for a newborn. These vital signs are more consistent with the normal findings for a school-age child.

REF: Text Reference: p. 177

21. Folic acid is extremely important during the first trimester of pregnancy. The client asks the nurse to recommend foods high in folic acid so that they may be included in her dietary intake. The nurse informs the client that a rich source of folic acid is:

a.

Ice cream

b.

Beef

c.

Orange juice

d.

Green, leafy vegetables

ANS: d

d. Foods rich in folic acid include green leafy vegetables, liver, kidney, and asparagus. More limited amounts may be found in milk, poultry, and eggs.

a. Ice cream is not a rich source of folic acid but does provide calcium.

b. Beef is not a rich source of folic acid but does provide protein.

c. Orange juice is not a rich source of folic acid but does provide vitamin C.

REF: Text Reference: p. 174

22. The nurse is caring for the newborn immediately after delivery. To reduce the newborns loss of heat through evaporation, the nurse should:

a.

Use the radiant warmer.

b.

Apply warm blankets.

c.

Dry the newborn and provide a cover.

d.

Move the newborn quickly to the nursery.

ANS: c

c. To reduce the newborns loss of heat through evaporation, the nurse should immediately dry the newborn after delivery and wrap the baby in a blanket.

a. To reduce the newborns loss of heat through radiation, the nurse should use a radiant warmer until the newborns temperature stabilizes.

b. To reduce the newborns loss of heat through conduction, the nurse should warm objects that have direct contact with the newborn and cover the newborns head.

d. Moving the newborn quickly to the nursery would not help reduce the newborns heat loss.

REF: Text Reference: p. 177

23. The nurse works in a pediatric medical day care center. An important aspect of his role is to determine whether the children are achieving developmental milestones. For a 12-month-old child, the nurse anticipates that he or she will just be able to:

a.

Creep on all four extremities.

b.

Ambulate independently.

c.

Place objects into a container.

d.

Use a palm grasp with fingers around an object.

ANS: c

c. A 12-month-old child should have the fine motor ability to place objects into a container.

a. A 9-month-old infant should have the gross motor ability to creep on all four extremities.

b. An 18-month-old child should have the gross motor ability to walk alone.

d. A 6-month-old infant should have the fine motor ability to use a palm grasp with fingers encircling an object.

REF: Text Reference: p. 181

24. The nurse in the elementary school is observing a 6-year-old childs level of development. At this stage, the nurse anticipates that the childs gross motor skills will enable this child to:

a.

Hop and jump onto small squares.

b.

Catch and throw a ball accurately.

c.

Play in an ice hockey game.

d.

Perform a standing high jump of 3 feet.

ANS: a

a. A 6-year-old child should have the gross motor skills to hop and jump onto small squares.

b. An 8- to 10-year-old child should possess the gross motor skills to catch and throw a ball accurately.

c. An 11- to 12-year-old child should possess the gross motor skills to play ice hockey.

d. An 11- to 12-year-old child should possess the gross motor skills to perform a standing high jump of 3 feet.

REF: Text Reference: p. 199

25. The nurse is working with a family who has just brought home a newborn. This is their first child and they have concerns about the babys nutrition. The nurse will recommend to the parents that they:

a.

Introduce solid foods at 3 months.

b.

Provide cereals and fruits after 6 months.

c.

Add honey to water to encourage intake.

d.

Use cows milk if the baby is not going to be breast-fed.

ANS: b

b. The introduction of cereals and fruits after 6 months of life provides iron and additional sources of vitamins.

a. The introduction of solid foods is not recommended before age 6 months because the gastrointestinal tract is not sufficiently mature to handle these complex nutrients, and infants are exposed to food antigens that may produce food protein allergies.

c. Honey should not be used in infants because of the potential for infant botulism poisoning.

d. All types of cows milk are not recommended in the first year because of the infants decreased ability to digest the contained fat. An iron-fortified commercially prepared formula should be used instead.

REF: Text Reference: p. 185

26. On the pediatric unit, the nurse is taking a preschoolers vital signs. The nurse compares the measurements obtained from this preschooler with the expected values for this age group which are:

a.

HR, 100; BP, 70/40; R, 40

b.

HR, 90; BP, 100/60; R, 32

c.

HR, 80; BP, 90/50; R, 24

d.

HR, 70; BP, 100/70; R, 16

ANS: c

c. The expected values for vital sign measurements in the preschooler are a heart rate of 60- to 100 beats per minute, a blood pressure averaging 92/56 mm Hg, and a respiratory rate of 23 to 25 breaths per minute. The vital sign measurements in this option would be within normal limits for the preschool-age child.

a. These are not normal vital sign values for a preschooler.

b. These are not expected values for a preschoolers vital signs.

d. These vital sign measurements are more consistent with those of a school-age child, not a preschooler.

REF: Text Reference: p. 193

Copyright 2005 by Mosby, Inc. All rights reserved.

Leave a Reply