Exam (elaborations) NURSING 2362 module 1

Questions
1.ID: 0A 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, what should the nurse tell the group about the infants? Rely on the fact that their needs will be met Correct Need to tolerate a great deal of frustration and discomfort to develop a healthy personality Must have needs ignored for short periods 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: Eliminate the option that contains the closed-ended word "must." Eliminate the options that are comparable or alike and indicate that experiencing frustration is necessary. Review: Erikson’s theory of psychosocial development as it relates to the infant.
Reference:
McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternalchild nursing (4th ed., pp. 74-75). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Developmental Stages
Giddens Concepts: Development, Reproduction
HESI Concepts: Developmental, Sexuality/Reproduction Awarded 1.0 points out of 1.0 possible points.
2.ID: 7A 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. Which action should the nurse take? Tell the mother that the infant's weight is increasing as expected Correct 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: Focus on the subject in the question, the current weight of the infant. 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.
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 488-489). St. Louis: Elsevier.
Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 143). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Development, Nutrition
HESI Concepts: Developmental, Nutrition Awarded 1.0 points out of 1.0 possible points.
3.ID: 2A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? Suspect the presence of hydrocephalus Suggest to the pediatrician that a skull x-ray be performed Tell the mother that the infant is growing faster than expected Document these measurements in the infant's health-care record Correct
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: Eliminate the options that are comparable or alike and indicate that the infant has a physiological problem. Review: the expected growth rate of an infant.
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 69, 489-490). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Clinical Judgment, Development
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Developmental Awarded 1.0 points out of 1.0 possible points.
4.ID: 1A 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." "The immune system of an infant is immature, and the infant is at risk for infection." Correct
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: 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.
References: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 477-478). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Development, Immunity
HESI Concepts: Developmental, Immunity Awarded 1.0 points out of 1.0 possible points.
5.ID: 1A nurse is assessing the language development of a 9-monthold infant. Which developmental milestone does the nurse expect to note in an infant of this age? The infant babbles. The infant says "Mama." Correct 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: Focus on the subject, the age of the infant. 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.
Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 94, 112). St. Louis: Elsevier.
Level of Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Developmental Stages
Giddens Concepts: Commuication, Development
HESI Concepts: Communication, Developmental Awarded 1.0 points out of 1.0 possible points.
6.ID: 7The 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. What should the nurse instruct the mother to do? 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 Give the infant cool liquids or a Popsicle and hard foods such as dry toast Correct
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 healthcare 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 options that are comparable or alike and involve administering medication to the infant. Review: the measures that will relieve the discomfort of teething.
Reference:McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 105). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Comfort, Development
HESI Concepts: Comfort—Pain, Developmental Awarded 1.0 points out of 1.0 possible points.