HESI 101 Module 1 Exam_ HESI VN_LATEST 2021,100% CORRECT

HESI 101 Module 1 Exam_ HESI VN_LATEST 2021 Question 1 1 / 1 pts A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson’s theory of psychosocial development, the nurse tells the group that infants have which developmental need? Correct! Need to rely on the fact that their needs will be met Must have needs ignored for short periods to develop a healthy personality Need to tolerate a great deal of frustration and discomfort to develop a healthy personality Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs Rationale: According to Erikson’s theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains the closed-ended word “must.” Eliminate the comparable or alike options and indicate that experiencing frustration is necessary. Review Erikson’s theory of psychosocial development as it relates to the infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Question 2 1 / 1 pts A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician’s office for a scheduled visit. The infant’s weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. The nurse should take which action? Correct! Tell the mother that the infant’s weight is increasing as expected. Tell the mother to decrease the daily number of feedings because the weight gain is excessive. Tell the mother that semisolid foods should not be introduced until the infant’s weight stabilizes. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate. Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz, at birth, a weight of 13 lb at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling that infants double their weight by 6 months of age will direct you to the correct option. Review the growth rate of an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Question 3 1 / 1 pts The nurse is assisting with data collection on a well-baby examination. The nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, the nurse should take which action? Report the presence of hydrocephalus to the health care provider. Suggest to the health care provider that a skull x-ray be performed. Tell the mother that the infant is growing faster than expected. Correct! Document these measurements in the infant’s health care record. Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant’s head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the infant has a physiological problem. Review the expected growth rate of an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages Question 4 1 / 1 pts A new mother asks the nurse, “I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?” Which statement should the nurse make in response to the mother? “Yes, your infant is protected from all infections.” "If you breastfeed, your infant is protected from infection." "The transfer of your antibodies protects your infant until the infant is 12 months old." Correct! "The immune system of an infant is immature, and the infant is at risk for infection." Rationale: Transplacental transfer of maternal antibodies supplements the infant’s weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age, the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed- ended word "all." Recalling that breastfeeding alone does not protect the infant from infection will assist you in eliminating the option that suggests breastfeeding protects the infant. From the remaining options, use the strategy of selecting the umbrella option to answer correctly. Review the physiological concepts related to the maturity of body systems in an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Question 5 1 / 1 pts A nurse is assisting with data collection on the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? The infant babbles. Correct! The infant says "Mama." The infant smiles and coos. The infant babbles single consonants. Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3- month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single- consonant babbling occurs between 6 and 8 months of age. Test-Taking Strategy: Use the process of elimination and focus on the subject, the developmental milestone of a 9-month-old. Recalling the language development that occurs during infancy will direct you to the correct option. Remember that an 8- to 9-month-old infant can string vowels and consonants together. Review the developmental milestones related to language development in an infant if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages Question 6 1 / 1 pts The mother of a 9-month-old infant calls the nurse at the pediatrician’s office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant’s discomfort. The nurse should provide which instruction? Schedule an appointment with a dentist for a dental evaluation. Rub the infant's gums with baby aspirin that has been dissolved in water. Obtain an over-the-counter (OTC) topical medication for gum-pain relief. Correct! Give the infant cool liquids or a Popsicle and hard foods such as dry toast. Rationale: Although sometimes asymptomatic, teething is often signaled by behavior such as nighttime awakening, daytime restlessness, an increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the health care provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child’s age, can relieve discomfort. Test-Taking Strategy: Focus on the subject, teething and relieving the infant’s discomfort. First recall that it is unnecessary to consult with a dentist. Next, eliminate the comparable or alike options that involve administering medication to the infant. Review the measures that will relieve the discomfort of teething if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Question 7 1 / 1 pts A nurse is teaching the mother of an 11-month-old infant how to clean the infant’s teeth. The nurse tells the mother to take which action? Correct! Use water and a cotton swab and rub the teeth. Use diluted fluoride and rub the teeth with a soft washcloth. Use a small amount of toothpaste and a soft-bristle toothbrush. Dip the infant's pacifier in maple syrup so that the infant will suck. Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant's pacifier in maple syrup is unacceptable because of the risk of tooth decay. Test-Taking Strategy: Use the process of elimination and focus on the subject, cleaning the teeth. Recalling the risk associated with tooth decay will help eliminate the option that identifies the use of maple syrup. To select from the remaining options, noting that the client in the question is an infant will direct you to the correct option. Review the procedure for cleaning teeth in an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? "I can mix the food in the my infant's bottle if he won't eat it." "Fluoride supplementation is not necessary until permanent teeth come in." Correct! "Egg white should not be given to my infant because of the risk for an allergy." "Meats are really important for iron, and I should start feeding meats to my infant right away." Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant’s intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant’s intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the health care provider’s recommendation, fruits and vegetables may be introduced first. Test-Taking Strategy: Read each option carefully and think about the subject, the principles associated with feeding and nutrition. Recalling that allergy is a concern will direct you to the correct option. Review the principles related to nutrition an infant if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. The nurse provides the mother with which instructions? Correct! To secure the infant in the middle of the back seat in a rear-facing infant safety seat To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car Rationale: Infants should not be restrained in the front seats of cars. If a passenger-side airbag is deployed, the airbag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that recommend placing the infant in the front seat. To select from the remaining options, keep safety in mind and remember that the infant should never be held and should be placed in an infant safety seat. Review car safety principles for an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Question 10 1 / 1 pts A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? "I need to keep large toys out of the crib." "The drop side needs to be impossible for my infant to release." "Wood surfaces on the crib need to be free of splinters and cracks." Correct! "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body." Rationale: The distance between slats must be no more than 2⅜ inches to prevent entrapment of the infant’s head and body. The mesh in a mesh-sided crib should have openings smaller than ¼ inch. The drop side must be impossible for the infant to release, and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother should avoid placing large toys in the crib because an older infant may use them as steps to climb over the side, possibly resulting in serious injury. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instructions” in the question. These words indicate a negative event query and the need to select the incorrect statement by the mother. Visualizing each of these options and keeping safety in mind will direct you to the correct option. Review crib safety instructions if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Question 11 1 / 1 pts The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? Initiative versus guilt Trust versus mistrust Industry versus inferiority Correct! Autonomy versus doubt and shame Rationale: According to Erikson, the toddler is struggling with the developmental task of acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers discover that they have wills of their own and that they can control others. Asserting their will and insisting on their own way, however, often lead to conflict with those they love, whereas submissive behavior is rewarded with affection and approval. Toddlers experience conflict because they want to assert their will but do not want to risk losing the approval of loved ones. Trust versus mistrust is the developmental task of the infant. Initiative versus guilt is the developmental task of the preschool-age child. Industry versus inferiority is the developmental task of the school-age child. Test-Taking Strategy: Focus on the data in the question. Note the relationship between the words "a will of his own" and the word "autonomy" in the correct option. Review Erikson's developmental stages if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 12 1 / 1 pts A nurse is planning care for a hospitalized toddler. To best maintain the toddler’s sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action? Spend as much time as possible with the toddler. Correct! Keep hospital routines as similar as possible to those at home. Allow the toddler to play with other children in the nursing unit playroom. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room. Rationale: The nurse can decrease the stress of hospitalization for the toddler by incorporating the toddler's usual rituals and routines from home into nursing care activities. Keeping hospital routines as similar to those of home as possible and recognizing ritualistic needs gives the toddler some sense of control and security and eases feelings of helplessness and fear. Spending as much time as possible with the toddler and allowing the toddler to play with other children and select the toys he would like to play with may be appropriate interventions, but keeping the hospital routine as similar as possible to the routine at home will best maintain the toddler's sense of control and security and ease feelings of helplessness and fear. Test-Taking Strategy: Note the strategic word "best" in the question. Use the process of elimination and focus on the subject, how to best maintain the toddler's sense of control and security and ease feelings of helplessness and fear. This will assist you in selecting the correct option. Review the psychosocial needs of the toddler with regard to hospitalization if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 13 1 / 1 pts A nurse in a day-care setting is planning play activities for 2- and 3-year-old children. Which toys are most appropriate for these activities? Correct! Blocks and push-pull toys Finger paints and card games Simple board games and puzzles Videos and cutting-and-pasting toys Rationale: Toys for the toddler should meet the child’s needs for activity and inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger paints, and bubbles; push– pull toys; large balls; sand and water play; blocks; painting; coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board games, videos, and cutting-and-pasting toys are more appropriate play activities for the preschooler. Test-Taking Strategy: Focus on the subject, toys appropriate for 2- to 3-year-old children. Remember that all parts of an option need to be correct for the option to be correct. Focusing on the age of the child will direct you to the correct option. Review age-appropriate toys for the toddler if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 14 1 / 1 pts A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn’t know what to do. The nurse should provide the mother with which advice? To separate her children during playtime That if the behavior continues, she will need to bring her children to a child psychologist Correct! That if she notes the behavior again, she should casually tell her children to dress and to direct them to another activity To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again Rationale: Sex play and masturbation are common among toddlers. Parents should respect the toddler's curiosity as normal without judging the toddler as bad. Parents who discover children involved in sex play may casually tell them to dress and direct them to another play activity, thereby limiting sex play without producing feelings of shame or anxiety. Bringing the children to a child psychologist, separating them at play, and punishing them are all inappropriate. Test-Taking Strategy: Use the process of elimination and focus on the strategic word “toddlers.” Recalling that sex play and masturbation are common among toddlers will direct you to the correct option. Review psychosexual development in the toddler if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 15 0.5 / 1 pts A nurse is assisting with data collection regarding the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform? Select all that apply. Put on and tie his shoes Correct! Align two or more blocks You Answered Dress himself appropriately Go to the bathroom without help Correct! Turn the pages of a book one at a time Question 16 1 / 1 pts A nurse is assisting with data collection regarding language development in a toddler from a bilingual family. The nurse expects which characteristic in the child’s language development? Correct! Is slower than expected Is developing as expected Is more advanced than expected Will require assistance from a speech therapist Rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. A child from a development. Test-Taking Strategy: Use the process of elimination. Note that there are no data in the question to indicate that the child needs assistance from a speech therapist. When selecting from the remaining options, noting the word "bilingual" in the question and recalling the factors that affect language development will direct you to the correct option. Review the factors that affect language development if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Cultural Diversity Question 17 1 / 1 pts A mother asks the nurse when her child should have his first dentist visit. The nurse provide which response? At age 3 Just before beginning kindergarten Twelve months after the first primary tooth erupts Correct! Soon after the first primary tooth erupts, usually around 1 year of age Rationale: The child should see the dentist soon after the first primary tooth erupts at around 1 year of age. Therefore the remaining options are incorrect. Parents should be aware of the dental guidelines for children and should not delay necessary dental care. Test-Taking Strategy: Use the process of elimination and recall the subject, the importance of dental care. Answer correctly by selecting the option that provides dental care at the earliest age. Review dental care guidelines if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Question 18 1 / 1 pts The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness? The child has been walking for 2 years. The child can eat using a fork and knife. The child no longer has temper tantrums. Correct! The child can remove his or her own clothing. Rationale: Signs of physical readiness for toilet training include the following: The child can remove her own clothing; is willing to let go of a toy when asked; is able to sit, squat, and walk well; and has been walking for 1 year. Using a fork and knife, walking for 2 years, and an absence of temper tantrums are not signs of physical readiness. Test-Taking Strategy: Use the process of elimination. Noting the strategic words "physical readiness" in the question will assist you in eliminating the option that addresses temper tantrums. To select from the remaining options, visualize each to help direct you to the correct option. Review the signs of physical readiness for toilet training if you had difficulty with this Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Question 19 1 / 1 pts The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat? Booster seat in a rear-facing position in the front seat Correct! Booster seat with one of the car's seat belts placed over the child Car safety seat in the back seat in a face-forward position Car safety seat in a face-forward position in the front seat Rationale: A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis. The child should not be placed in the front seat. A car safety seat is used for the child who weighs less than 40 lb. These seats are placed in the middle of the back seat in a rear-facing position. Test-Taking Strategy: Use the process of elimination and note that the child weighs 45 lb. Keeping the subject of safety in mind and visualizing each of the options will direct you to the correct option. Review car safety measures if you had difficulty with this question. Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 20 1 / 1 pts The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. The nurse tells the mother that the child should have a dental examination how frequently? Once a year Every 3 months Correct! Every 6 months Whenever a new primary tooth erupts Rationale: Dental examinations for a 4- to 5-year-old child should be conducted every 6 months. Every 3 months, once a year, and whenever a new primary tooth erupts are all incorrect. Test-Taking Strategy: Knowledge of the subject, the schedule for dental examinations for a 5- year-old child is needed to answer this question. Recalling the general principles related to dental care and thinking about dental health care of an adult will help direct you to the correct option. Review dental-care principles for a child if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 21 1 / 1 pts A nurse, planning play activities for a hospitalized school-age child, uses Erikson’s theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing which developmental goal? Initiative Autonomy A sense of trust Correct! A sense of industry Rationale: According to Erikson, the central task of the school-age years is the development of a sense of industry. The school-age child replaces fantasy play with "work" at school, crafts, chores, hobbies, and athletics. Development of trust is the task of infancy. Development of autonomy is the task of toddlerhood. Development of initiative is the task of the preschooler. Test-Taking Strategy: Use knowledge regarding the subject, Erikson’s stages of psychosocial development, to answer the question. Focusing on the words “school-age child” will help direct you to the correct option. Review Erikson’s stages of psychosocial development if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 22 0 / 1 pts A nurse, assigned to care for a hospitalized child who is 8 years old, assists with planning care, taking into account Erik Erikson’s theory of psychosocial development. According to Erikson’s theory, which task represents the primary developmental task of this child? Correct Answer Mastering useful skills and tools Gaining independence from parents You Answered Developing a sense of trust in the world Developing a sense of control over self and body functions Rationale: According to Erikson's theory of psychosocial development, the school-age child's task is to master useful skills and tools of the culture (industry versus inferiority). Gaining independence from parents is the psychosocial task of the adolescent. Developing a sense of trust in the world is the psychosocial task of an infant. Developing a sense of control over self and body functions is the psychosocial task of the toddler. Test-Taking Strategy: Focus on the strategic words “8 years old” in the question and think about the developmental level of the child. Use knowledge of Erikson’s theory of psychosocial developmental to answer this question. Review Erikson’s theory of psychosocial development if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Question 23 0 / 1 pts A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action? You Answered Brush their teeth every morning and at bedtime Correct Answer Brush and floss their teeth after meals and at bedtime Brush and floss their teeth every morning and at bedtime Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime Rationale: School-age children are able to assume responsibility for their own dental hygiene. Good oral health habits tend to be carried into the adult years, helping prevent cavity formation for a lifetime. Thorough brushing with fluoride toothpaste followed by flossing between the teeth should be done after meals and before bedtime. It is important that parents set up a routine schedule for the child that promotes good daily oral hygiene and gives them responsibility for their own dental care. Test-Taking Strategy: Use the process of elimination. Use the process of elimination. Use the subject, general principles and guidelines related to dental care and select the option that provides the most frequent and thorough dental care. Review principles and guidelines of dental care if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 24 1 / 1 pts The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should provide which response to the parents? Correct! That this is normal behavior for an adolescent To restrict any social privileges until the behavior stops That this type of behavior is usually the result of parents' spoiling a child That their daughter will need to see a child psychologist if the behavior continues Rationale: Identity formation is the major developmental task of adolescence. Energy is focused within the self, and the adolescent is sometimes described as egocentric or self-absorbed. Frustrated parents often describe teenagers during this phase as self-centered, lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on himself or herself, and determine who he or she is going to be. Erikson describes the conflict of this phase of psychosocial development as identity formation versus role confusion. The assertions that a psychologist is needed and that the behavior is the result of spoiling are incorrect. Restriction of social privileges will cause resentment and rebellion in the adolescent. Test-Taking Strategy: Focus on the adolescent’s behaviors described in the question. Recalling the subject, stages of psychosocial development according to Erikson will direct you to the correct option. Remember that identity formation is a major developmental task of adolescence. Review the psychosocial development of the adolescent if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 25 1 / 1 pts A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse assists with planning care knowing that which is the most likely primary concern of the teenager? Correct! Body image Obtaining adequate nutrition Keeping up with schoolwork Obtaining adequate rest and sleep Rationale: Body image is of particular importance to an adolescent. Teenagers tend to be concerned about their weight, complexion, sexual development, and acceptance by their peers. They are not as concerned about obtaining adequate nutrition and tend to eat fast foods and junk foods and may experiment with weight-management techniques such as fasting, diet pills and laxatives, self-induced vomiting, and fad diets. Keeping up with schoolwork may be important to some teenagers, but it is not usually the primary concern. Along with engaging in increasingly independent activities, teenagers tend to stay up late and have difficulty waking in the morning. Obtaining adequate rest and sleep is not teenagers’ primary concern. Test-Taking Strategy: Note the strategic word "primary." Thinking about the psychosocial development of the teenager (adolescent) will direct you to the correct option. Review psychosocial development of the adolescent if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 26 1 / 1 pts The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother? Hepatitis B is a concern with body piercing Infection always occurs when body piercing is done Correct! Body piercing is generally harmless as long as it is performed under sterile conditions It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV) Rationale: Generally body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some of the complications that may occur are bleeding, infection, keloid formation, and the development of allergies to metal. The area needs to be cleaned at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not associated with body piercing; however, they are a possibility with tattooing. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed- ended word "always." The fact that HIV and hepatitis B are not associated with body piercing will help you eliminate these options. Review the complications associated with body piercing if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Safety Question 27 1 / 1 pts A sexually active adolescent asks the school nurse about the use of latex condoms and the reduction of the risk of sexually transmitted infections (STIs). The nurse provides which information to the adolescent? Correct! Use of a latex condom can reduce the risk of transmission of STIs. The only way to reduce the risk of transmission of STIs is abstinence. Use of a latex condom is a good method for preventing pregnancy. A spermicide needs to be used along with a condom to prevent transmission of STIs. Rationale: Use of a condom during intercourse can reduce the risk of STI transmission. Abstinence is not the only way to reduce the risk of STI transmission. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs. Test-Taking Strategy: Use the process of elimination and focus on the subject, reduction of the risk of transmission of an STI. Eliminate the option using the closed-ended word “only.” Focusing on the subject will help you select the correct option from the remaining options. Review the methods of reducing the risk of transmission of STIs if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Infection Control Question 28 1 / 1 pts A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult for which reason? Yong adults are at risk for a serious illness. Young adults are unable to afford health insurance. Young adults are exposed to hazardous substances. Correct! Young adults may ignore physical symptoms and postpone seeking health care. Rationale: Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help the nurse and client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and other chronic diseases. Young adults are not at risk for serious illness. The young adult may or may not be exposed to hazardous substances and may or may not be able to afford health insurance. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, a characteristic of young adults, will direct you to the correct option. Review the characteristics associated with the young adult if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 29 1 / 1 pts A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. The young adult is sensitive to criticism. The young adult verbalizes unrealistic fears. The young adult verbalizes disappointment with life. Correct! The young adult verbalizes satisfaction with friendships. Correct! The young adult has a sense of meaning and direction in life. Rationale: Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Signs of emotional health in the young adult include a sense of meaning and direction in life, successful negotiation of transitions, absence of feelings of being cheated or disappointed by life, attainment of several long-term goals, satisfaction with personal growth and development, reciprocated feelings of love for a partner, satisfaction with social interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and no unrealistic fears. Test-Taking Strategy: Focus on the subject, a sign of emotional health. Select the options that use positive words such as “satisfaction” and “meaning and direction.” Review the signs of emotional health in the young adult if you had difficulty with this question. Level of Cognitive Ability: Analyzing Content Area: Health Assessment/Physical Exam Question 30 0 / 1 pts According to Erik Erikson’s developmental theory, which choice is a developmental task of the middle adult? Redefining self-perception and capacity for intimacy Correct Answer Providing guidance during interactions with his children Verbalizing readiness to assume parental responsibilities You Answered Making decisions concerning career, marriage, and parenthood Rationale: According to Erikson’s developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Making decisions concerning career, marriage, and parenthood; redefining self-perception and capacity for intimacy; and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult. Test-Taking Strategy: Use the process of elimination. Eliminate comparable or alike options that relate to marriage and parenting. Also, focusing on the subject, a middle adult, will direct you to the correct option. Review the developmental tasks of the middle adult if you had difficulty with this question. Integrated Process: Nursing Process/Assessment Content Area: Developmental Stages Question 31 1 / 1 pts A nurse is participating in a planning conference to improve dietary measures for an older client who is experiencing dysphagia. Which action should the nurse suggest including in the plan of care? Encouraging the client to feed herself Ensuring that most of the diet consists of liquids Correct! Monitoring the client during meals to ensure that food is swallowed Consulting with the physician regarding feeding through an enteral tube Rationale: Clients with dysphagia must be assisted during meals, and the nurse should carefully observe the client to ensure that foods are successfully swallowed instead of being trapped in the mouth. The diet should be nutritionally balanced and consist of both solids and liquids. Aspiration of liquids or solids is possible and may lead to aspiration pneumonia. Thickeners can be added to liquids because thin liquids are most difficult to swallow for clients with dysphagia. Clients with severe dysphagia may require enteral tube feedings, but there is no information in the question to indicate that the dysphagia is severe. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. This will direct you to the correct option. Remember that one risk that exists with dysphagia is aspiration. Review nutritional measures for the older client with dysphagia and dysphagia precautions if you had difficulty with this question. Integrated Process: Nursing Process/Planning Content Area: Safety Question 32 1 / 1 pts An older client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. On the basis of these reported data, the nurse should take which action? Report the findings to the registered nurse. Correct! Document the findings in the medical record. Ask the registered nurse to obtain a prescription for a nighttime sedative. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours. Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Because the reported data are normal age-related changes, the nurse would document the findings. There is no reason to report the findings to the registered nurse. Sedatives should be avoided. The consumption of caffeinated beverages is likely to increase disruption of sleep patterns. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the age-related changes related to sleep patterns and remembering that those described in the question are normal will direct you to the correct option. Review age-related sleep pattern changes if you had difficulty with this question. Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Question 33 1 / 1 pts A nurse is assisting with developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan? Encouraging at least one daytime nap Discouraging the use of a nightlight at bedtime Correct! Encouraging bedtime reading or listening to music Discouraging social interaction, particularly at bedtime Rationale: Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading or listening to music. The use of a nightlight will foster an environment that is both helpful and safe. Test-Taking Strategy: Use the process of elimination. Thinking about the safety needs of the older client will assist you in eliminating the option of discouraging the use of a nightlight. To select from the remaining options, focusing on the subject, maintaining an adequate sleep pattern, will direct you to the correct option. Review measures that will maintain an adequate sleep pattern if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 34 1 / 1 pts A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. Which should be the nurse’s next action? Report the client’s concern to the health care provider. Correct! Ask the client about medications he is taking. Document the client’s concern in the medical record. Tell the client that sexual dysfunction is a normal age-related change. Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. Although the nurse may report the client’s concern and document the concern in his medical record, the next action is to ask the client about the medications he is taking. Test-Taking Strategy: Use the steps of the nursing process to answer the question. This will direct you to the correct option, which is the only option related to data collection. Review the causes of sexual dysfunction in the older client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 35 1 / 1 pts A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information? It is best to do grocery shopping and other errands late in the day. Clients must stay in the house and ask a neighbor or family member to run their errands. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza. Correct! Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season. Rationale: During peak influenza season, older clients should avoid crowds to decrease the risk of contracting influenza. The nurse should encourage clients to do their shopping and other errands early in the morning, when crowds are smaller, or to have someone else shop for them. Frequent hand hygiene is the best means of avoiding transmission of the flu virus. Drinking eight 8-oz glasses of fluid a day will not reduce the risk of contracting influenza; however, it will prevent dehydration if illness occurs. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed- ended word “must.” Also eliminate the option that uses the words “late in the day.” To select from the remaining options, focusing on the subject of the question, how to decrease the risk of contracting influenza, will direct you to the correct option. Review interventions used to decrease the risk of contracting influenza if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Infection Control Question 36 1 / 1 pts A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client’s ability to maintain a patent airway because of which factor involved in the normal aging process? Increased production of surfactant Increased respiratory system compliance Correct! Decreased older client’s ability to clear secretions Decreased number of alveoli and increased function of those remaining Rationale: Respiratory changes related to the normal aging process decrease an older adult’s ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished. Test-Taking Strategy: Use knowledge of the subject, normal age-related changes in the older client. Note the relationship between the words “maintain a patent airway” in the question and “ability to clear secretions” in the correct option. Review the normal age-related changes of the respiratory system if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Adult Health/Respiratory Question 37 1 / 1 pts An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? "It is caused by hereditary factors." Correct! "A loss of melanin occurs in the normal aging process." "The skin on the scalp becomes thin, causing moisture to escape." "The number of sweat glands and blood vessels decreases in the normal aging process." Rationale: The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from ultraviolet rays, paler skin color, and graying hair. Although the skin becomes thinner with the aging process and the number of sweat glands and blood vessels decreases, these changes are unrelated to graying hair. Heredity factors influence when the process of graying begins but do not cause the graying of hair. Test-Taking Strategy: Use knowledge of the subject, and recall the normal process of aging. Note the relationship between the words “turned gray” in the question and “loss of melanin” in the correct option. Review the age-related changes related to the hair if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 38 1 / 1 pts A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? "I should drink extra fluids during the summer." "I should wear cool, light clothing in warm weather." "I need to wear a hat with a wide brim when I go outdoors." Correct! "I need to wear additional antiperspirant and deodorant in warm weather." Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and reduced evaporative heat loss because of decreased sweating. The need for antiperspirants and deodorants is decreased. However, older adults are at a greater risk of heatstroke as a result of a compromised cooling mechanism; they should therefore avoid heat exposure over long periods and in areas of high humidity. The older adult should wear a hat with a wide brim and cool, lightweight, light-colored clothing when outdoors. It is also important that the older adult maintain adequate hydration, particularly during the summer and in hot climates. Test-Taking Strategy: Focus on the subject, heatstroke, and note the strategic words “need for further instruction.” These words indicate a negative event query and the need to select the incorrect option. Recall that with aging, bodily changes occur, including a decrease in the number of sweat glands. This will help direct you to the correct option. Review these age-related changes to the skin if you had difficulty with this question. Level of Cognitive Ability: Evaluating Content Area: Developmental Stages Question 39 1 / 1 pts A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider? Correct! “It looks like I have a blank spot in the middle of what I’m trying to see.” “I have to hold my newspaper farther and farther away from me when I read.” “If I go from a very bright room to a very dark room, I have some trouble adjusting.” “I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me.” Rationale: Seeing blank spots in the middle of an object is loss of central vision, a symptom of macular degeneration, which would require an immediate discussion with the health care provider. Having to hold close objects farther away is presbyopia, a normal finding with aging. With normal aging, the lens of the eye loses the ability to quickly adjust to changes in lighting. Slight changes in color perception are common with aging. Test-Taking Strategy: Use knowledge of the subject, visual changes with aging, to assist with answering this question. Losing central vision (or any actual loss of vision) is not normal and would warrant an immediate discussion with the health care provider. Review expected changes in vision with aging if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Question 40 1 / 1 pts A nurse is reviewing the medical record of an older client with presbycusis. Which finding would the nurse expect to note in the client’s record? Unilateral conductive hearing loss Difficulty hearing low-pitched tones Correct! Difficulty hearing whispered words in the voice test Improved hearing ability during conversational speech Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and difficulty hearing consonants during conversational speech. Test-Taking Strategy: Use knowledge of the subject, hearing changes in older adults. Eliminate the option containing the words “increased hearing.” Recalling that the hearing loss in presbycusis is bilateral will assist you in eliminating the option containing the word “unilateral.” For you to select from the remaining options, it is necessary to know that the client has difficulty hearing high-pitched tones (not low-pitched tones). Review age-related changes in hearing if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Question 41 0 / 1 pts A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding? You Answered Thin, ridged toenails Thick skin on the lower legs Bounding dorsalis pedis pulse Correct Answer Loss of hair on the lower legs Rationale: In later adulthood, the dorsalis pedis and posterior tibial pulses may become more difficult to find. They would not be bounding. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick, ridged nails; loss of hair on the lower legs) also occur normally with aging. Test-Taking Strategy: Use knowledge of the subject, changes related to aging in the skin and peripheral vascular systems. Recalling the age-related changes in the skin and cardiovascular system and noting the words “loss of hair” will direct you to the correct option. Review age- related changes in the skin and peripheral vascular systems if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Question 42 1 / 1 pts The nurse notes that a client in later adulthood has tremors of the hands. On the basis of this finding, the nurse should take which action? Correct! Document the findings. Notify the registered nurse immediately. Obtain a prescription for a muscle relaxant. Ask the registered nurse about referring the client to a neurological specialist. Rationale: Senile tremors are occasionally noted in clients in later adulthood. These benign tremors include intentional tremor of the hands, head-nodding (as if saying “yes”), and tongue protrusion. Because this finding is an age-related occurrence, obtaining a prescription for a muscle relaxant, notifying the registered nurse immediately, and asking about referring the client to a neurological specialist are unnecessary and incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate contact with the registered nurse. Review age-related changes of the neurological system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action? Uses short sentences Correct! Overarticulates words Uses facial expressions or gestures Speaks at a normal rate and volume Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker's face and lips. The nurse would watch to see that the nursing assistant avoided situations in which there is a glare or shadows on the client's field of vision. The nurse would also remind the assistant to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The assistant should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues. Test-Taking Strategy: Note the strategic word “intervene” in the question. This word indicates that you need to select the option that indicates an incorrect action by the nursing assistant. Visualize each of the options to help direct you to the correct one. Review strategies to improve communication when a client has hearing loss if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation A nurse is assisting with gathering subjective data from a client during a health assessment and plans to ask the client about the medical history of the client’s extended family. About which family members would the nurse ask the client? Wife and wife's parents Foster children and their parents Wife's children from a previous marriage Correct! Aunts, uncles, grandparents, and cousins Rationale: The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of a husband and a wife and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint living situation. Test-Taking Strategy: Use the process of elimination. Focusing on the strategic words "extended family" in the question will direct you to the correct option. Review family structures if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Data Collection/Physical Exam Question 45 1 / 1 pts from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications? The client's son The client's father Correct! The client's mother The client's grandson Rationale: African American families are oriented around women. Within the African American family structure, the wife/mother is often charged with the responsibility of protecting the health of family members. The African American woman is expected to assist each family member in maintaining good health and in determining the course of treatment if a family member becomes ill. The nurse must recognize the importance of the African American woman in disseminating information and in assisting the client in making decisions. Although the African American man may be included in the decision-making process, the African American family is often matrifocal, so the nurse ensures that the woman is present. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that identify male members of the family. Review the characteristics of the African American family system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Cultural Diversity Question 46 1 / 1 pts A female client asks a nurse about the advantages of using a female condom. The nurse discusses which advantage with the client? That it can be used along w