Nokea
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. This is because at the age of 2, children often exhibit behaviors such as saying 'no' and resisting help as they start to assert their independence and autonomy. This behavior is a normal part of their development as they strive to explore their own abilities and assert control over their environment. Choices B, C, and D are incorrect because at this age, the child is not yet focused on developing a sense of trust, managing anger, or finishing projects. It is important to recognize and support the child's need for independence while providing guidance and setting appropriate boundaries.
You may also like to solve these questions
A nursing instructor is reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in a client record?
- A. Cover errors with correction fluid and write in correct info
- B. Put date & time on all entries
- C. Document objective data
- D. leaving out opinions
- E. Use as many abbreviations as possible
Correct Answer: B,C
Rationale: The correct answers are B and C. Putting date and time on all entries ensures accuracy and accountability. Documenting objective data maintains professionalism and avoids subjective bias. Choice A is incorrect as it can be considered tampering with records. Choice D is incorrect as opinions should be avoided for objectivity. Choice E is incorrect as excessive abbreviations can lead to misinterpretation.
Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct choices for the nurse to include in the discussion with the middle adult are Varicella, Herpes zoster, and Seasonal influenza. Varicella (chickenpox) and Herpes zoster (shingles) are important vaccinations to prevent these viral infections, especially in middle-aged adults who may be at higher risk. Seasonal influenza vaccination is also crucial for middle adults to protect against flu-related complications. Haemophilus influenzae type b is typically given to children under 5, so it is not relevant for this age group. HPV vaccination is recommended for younger individuals to prevent certain cancers.
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when a new nurse states that a client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke leads to severe dehydration and vasodilation, causing a drop in blood pressure (hypotension). Bradycardia (B), clammy skin (C), and bradypnea (D) are not characteristic of heat stroke. Bradycardia is a slow heart rate, while heat stroke typically causes tachycardia. Clammy skin is more indicative of shock or hypoglycemia, not heat stroke. Bradypnea is slow breathing, but heat stroke usually leads to rapid, shallow breathing. Therefore, hypotension is the most appropriate choice as it aligns with the physiological response to heat stroke.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents
- B. It's been so stressful for me to even think about having my own family
- C. I don't even know who I am yet, & now I'm supposed to know what to do
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father
Correct Answer: C
Rationale: The correct answer is C because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.
Nurse educator is reviewing with newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. Nurse indicates understanding when she states that which are manifestations of systemic?
- A. Fever
- B. Malaise
- C. Edema
- D. Pain/tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A,B,E
Rationale: The correct answer is A, B, and E. Systemic infection manifests with fever, malaise, and an increase in pulse and respiratory rate. Fever is the body's response to infection, malaise is a general feeling of discomfort, and increased pulse and respiratory rate indicate the body's effort to fight infection. Edema and pain/tenderness are more indicative of localized infection rather than systemic. In summary, the correct manifestations of systemic infection are fever, malaise, and an increase in pulse and respiratory rate, while edema and pain/tenderness are more likely to be seen in localized infections.