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A nurse assessing a 4-month-old infant would expect the infant to do which of the following?
- A. Crawl up the stairs.
- B. Creep on the floor at least 30 ft.
- C. Walk upright with a waddling gait.
- D. Hold head at a 90-degree angle while prone.
Correct Answer: D
Rationale: At 4 months the infant is able to hold the head up steadily to a 90-degree angle while in the prone position. Infants may crawl at 7 months and creep at about 9 months. Standing with support and walking occur at about 8 to 15 months.
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The nurse performing a routine physical assessment on a 25-year-old understands that the patient is most likely experiencing which of the following?
- A. A gradual decline in physical capabilities
- B. Optimal level of functioning
- C. Slight diminishing of visual acuity
- D. Minimal hearing loss
Correct Answer: B
Rationale: During early adult years, the body is at an optimal level of functioning. The gradual decline in physical capabilities, diminishing of visual acuity, and hearing loss will not occur until later in adulthood.
A mother asks the nurse when she should introduce solid foods into her infant's diet. What would be the most correct response?
- A. Introduce fruits and vegetables first.
- B. Mix foods to allow the infant variety.
- C. Introduce only one new food at a time.
- D. Introduce new foods at 24-hour intervals.
Correct Answer: C
Rationale: Only one new food should be introduced at a time, followed by several days between new foods. Cereals should be introduced first, followed by fruits and vegetables, and last meats. Food should not be mixed to allow the infant to develop interest in different foods and tastes.
According to Piaget what is the cognitive developmental level of the adolescent?
- A. Concrete operational stage
- B. Sensorimotor stage
- C. Preoperational stage
- D. Formal operational stage
Correct Answer: D
Rationale: The formal operational stage is the cognitive developmental level of adolescence.
Separation anxiety includes which stages?
- A. Detachment
- B. Protest
- C. Anger
- D. Despair
- E. Withdrawal
Correct Answer: A,B,D
Rationale: The phases of separation anxiety are protest, despair, and detachment.
A nurse teaching the mother about infant oral hygiene instructs the mother to offer the infant sips of:
- A. cola.
- B. milk.
- C. juice.
- D. water.
Correct Answer: D
Rationale: Oral hygiene for the young infant consists of offering sips of clear water and wiping and massaging the infant's gums. Cola, milk, and juice should not be introduced at this young age.