Developmental Stages - Saunders nclex review PDF

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A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? Rationale: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

4.

Remain with the family member without discussing funeral arrangements.

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. Rationale: A focused data collection process is centered around a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

1.

Listening to lung sounds

2.

Obtaining the client's temperature

4.

Obtaining information about the client's respirations

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client? Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Clients with respiratory distress use other chest muscles to breathe. Muscle retraction is observed at the sternum and between the ribs. Stridor is a harsh crowing sound noted with an upper airway obstruction and often signals a lifethreatening emergency. Cyanosis is bluish coloration of the lips occurring as a result of poor oxygenation of the circulating blood. Diminished lung sounds are heard over lung

tissue where poor oxygen exchange is occurring. Fever (elevated temperature) occurs with a respiratory infection such as pneumonia. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces) and often causes chest discomfort with inspiration.

3.

Wheezes and use of accessory muscles

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply. Rationale: In the Romberg test, the client is asked to stand with the feet together, the arms at the sides, and to close the eyes and hold the position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. The nurse should determine the client's risk for falling by collecting data. Because the client has difficulty maintaining balance, the nurse should instruct the client to ask for assistance when getting up or walking. Decreasing the light in the environment is done if a client has photophobia (sensitive to light). Clients with a shuffling gait as with Parkinson's disease should lift their legs high when walking. Clients experiencing dysphagia, which often occurs with stroke, should eat sitting upright and perform double swallowing.

1.

Collect data to determine factors for fall risk.

3.

Instruct the client to ask for assistance when getting up to walk.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially? Rationale: Cheyne-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia. The nurse should initially obtain data about neurological functioning, starting with determining the client's ability to respond to verbal stimuli. Listening to heart sounds is important but is secondary to determining the neurological status. There is no information related to the need to check for a pulse deficit (difference between the apical and radial pulse). The use of incentive spirometry is indicated for shallow breathing and postoperatively.

4.

Determine the client's ability to follow verbal commands.

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.

Rationale: A conductive hearing loss is as a result of a physical obstruction to the transmission of sound waves. Acute otitis media with effusion, a fluid buildup in the middle ear, can block the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

2.

Acute otitis media with effusion

5.

A physical obstruction to the transmission of sound waves

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur? Rationale: A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. It occurs from increased or abnormal blood flow through the valves of the heart. Lub-dub sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound that occurs with pericarditis. A click is described as an abrupt, high-pitched snapping sound.

3.

Gentle, blowing or swooshing noise

The nurse is preparing to assist the health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done? Rationale: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. The Ishihara chart is used to detect color blindness. A Snellen eye chart is used to determine visual acuity and cranial nerve II (optic nerve) functioning. Testing the corneal light reflex, shining a penlight in the eyes of a client gazing straight ahead, should demonstrate the corneal reflection in the exact position in each eye and parallel alignment.

4.

Testing the six cardinal positions of gaze

The nurse is reinforcing instructions for a client in how to perform a testicular selfexamination (TSE). Which instructions should the nurse include? Select all that apply. Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. This will provide ease in palpating, and the client will be better able to identify any

abnormalities. The nurse should instruct the client to select a day of the month and perform the examination on the same day each month to avoid forgetting to do the examination. TSE is done by the client rolling each testicle between the thumb and fingers. The client should seek medical attention if a lump, mass, or swelling of the testicle is detected. The bladder does not have to be empty to complete the examination. There is no connection between urethral discharge and TSE.

1.

Perform TSE after a shower or bath.

3.

Perform TSE on the same day each month.

5.

Perform TSE by rolling each testicle between the thumb and fingers.

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings should the nurse expect to observe because of meningeal irritation? Select all that apply. Rationale: Meningitis is the inflammation of the meninges, the membranes covering the brain and spinal cord. It is caused by organisms such as bacteria, viruses, or fungi. The client with meningitis experiences discomfort when pressure is placed on certain areas that irritate the inflamed meninges. Neck stiffness (nuchal rigidity) is an early sign of meningitis. A positive Brudzinski's sign is observed if the supine client passively flexes the hip and knee in response to neck flexion by the examiner and the client reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Unequal pupils and slowed pupillary response to light is a sign of increased intracranial pressure. This may occur in clients who are critically ill, but it is not a sign of meningeal irritation. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. This posturing occurs with severe brain damage and the client requires emergency medical attention. 2.

The client reports stiffness and soreness in the neck area.

3.

The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion.

4.

The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory? Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal morality. The other options are correct statements regarding Kohlberg's theory.

1.

"Individuals move through all six stages in a sequential fashion."

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response? Rationale: According to Erikson, at ages 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents. Therefore, the other options identify incorrect responses.

4.

"At this age, the child is developing his or her own personality."

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take? Rationale: According to Jean Piaget's theory of cognitive development, it is normal for the infant or toddler not to recognize that objects continue to be in existence, even if out of the visual field; however, this is abnormal for a 6-year-old. If a 6-year-old child does not recognize that objects still exist even when outside the visual field, the child is not progressing normally through the developmental stages. The nurse should report this finding to the health care provider. Options 1, 2, and 4 delay necessary follow-up and treatment.

3.

Report the observation to the primary health care provider.

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents? Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, the infant will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the

development of trust and lead to the mistrust of others. Therefore, the remaining options are incorrect.

1.

Allow the infant to signal a need.

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent? Rationale: According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents" wishes. Saying things like "no" and "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Punishing the child every time the child says "no" is likely to produce a negative response.

1.

Set limits on the child's behavior.

The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which? Rationale: According to Erikson, the later years of life are from 65 years of age until death. The adult reminisces about past life experiences, often viewing them in a positive way. The adult needs to feel good about his or her accomplishments, see successes in his or her life, and feel that he or she has made a contribution to society.

2.

A normal psychosocial response

The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development? Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion, but not everyone reaches stages 5 and 6 during his or her development of personal morality. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It also states that moral development progresses in relation to cognitive development, and a person's ability to make moral judgments develops over a period of time. In stage 1 (ages 2–3 years; punishment–obedience orientation), children cannot reason as mature members of society because they are too young to do so. A child obeys rules to avoid punishment. It is appropriate for a parent to explain limitations, and to provide

distractions. In the egocentric stage, an infant has no concept of right or wrong. A child who is in the law-and-order orientation stage obeys laws to maintain social order. In the good boy–nice girl orientation stage, a child behaves in a way to avoid displeasing others.

3.

Punishment–obedience stage

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? Rationale: In the preoperational stage, the child is demonstrating egocentric thinking by believing the moon's actions revolve around the child. In the sensorimotor stage, a child does not believe an object exists if it is not in sight. A child in the concrete operations stage is able to classify, order, and sort facts, such as the multiplication tables. A child in the formal operations stage is able to solve more complex problems, such as using a map to determine location and directions.

4.

"The moon follows me, and goes to bed when I go to bed".

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development? Rationale: According to Kohlber's theory of moral development, during the good boy–nice girl orientation, the child acts in a way to please other people. Sharing is an example of this behavior. A child in the egocentric judgment stage has no awareness of right or wrong. A person in the law-and-order orientation stage obeys laws to maintain social order. During the social contract and legalistic orientation stage, a person is aware that others may have another set of values and opinions.

3.

Good boy–nice girl orientation

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage? Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces. Self-gratification relates to the oral stage. Tapering off of conscious biological and sexual urges relates to the latency period. Association with pleasurable and conflicting feelings about genital organs relates to the phallic stage.

2.

Beginning of toilet training

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response? Rationale: The sleep patterns of the adolescent vary some according to individual needs. However, in general, adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school. Options 2, 3, and 4 are incorrect.

1.

"Adolescents love to sleep late in the morning."

A 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development? Rationale: Adolescents are not often sure they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety. Ideally, the peer group will support the ill friend. The other options isolate the child from the peer group.

4.

Allow the child to participate in activities with other individuals in the same age group when the condition permits.

Which interventions are appropriate for the care of an infant? Select all that apply. Rationale: Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to also do ...