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Chapter 012

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 12: Conception Through Adolescence MULTIPLE CHOICE 1. Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy? 1. Detection of fetal movement 2. Observation that the uterus is below the pubis 3. Confirmation of the desire to breast- or bottle-feed 4. Determination of the presence of morning sickness ANS: 1 During the second trimester, between 16 an
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 1: Con!eption Through doles!en!e#$%TP%E C'(CE 1.Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy?1.Detection of fetal movement2.Observation that the uterus is below the pubis3.Confirmation of the desire to breast or bottlefeed!.Determination of the presence of morning sic ness #$%&1During the second trimester' between 1( and 2) wee s* gestation' the mother begins to feel fetal movement. During the second trimester' the uterus should be above the level of the symphysis pubis. Confirmation of the desire to breast or bottlefeed is more li ely to ta e place during the third trimester. +orning sic ness is most li ely to occur during the first trimester.D,-&C/-&101O&#nalysisO4&$ursing 4rocess& #ssessment+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9#nte9,ntra94ostpartum and $ewborn Care: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments2.Which one of the following newborn refle;es should the nurse be able to elicit at a (month wellbaby visit?1.+oro 2.%tartle3.abins i !./;trusion#$%&3he abins i refle; is a normal refle; found in a (monthold infant. he +oro refle; is seen in the newborn. he startle refle; is seen in the newborn. efore ( months of age' the e;trusion refle; causes food to be pushed out of the mouth. ,t is normally present from birth to ! months.D,-&#O&<nowledgeO4&$ursing 4rocess& #ssessment+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9#nte9,ntra94ostpartum and $ewborn Care: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments3.,n evaluating an infant*s physical status and growth' the nurse e;pects to find&1.irth weight triples by ( months 2.#nterior fontanel closes ! to = wee s after birth +osby items and derived items > 2))' 2))0 by +osby' ,nc.' an affiliate of /lsevier ,nc.  est an  3.Chest circumference is larger than head circumference at 12 months !.irth height increases 1 inch each month for the first ( months #$%&!8eight increases an average of 1 inch during each of the first ( months and inch the ne;t ( months. irth weight doubles in appro;imately 0 months and triples by 12 months.he anterior fontanel closes at about 12 to 1= months. he head and chest circumference are e@ual at 1 year of age.D,-&#/-&100O&<nowledgeO4&$ursing 4rocess& #ssessment+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9#nte9,ntra94ostpartum and $ewborn Care: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments!.Apon evaluation of a (monthold infant*s developmental status' the nurse e;pects that the child at this age will be able to&1.Completely roll over 2.4ull self to a standing position3.Creep on all four e;tremities!.#ssume a sitting position independently #$%&1# (monthold infant is able to roll over. # monthold infant is able to pull self to a standing position' creep on all four e;tremities' and attain a sitting position independently.D,-&#O&<nowledgeO4&$ursing 4rocess& #ssessment+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9Browth and Development: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments0.-or a 2yearold child' cognitive development is characteried by&1.ecogniing right and wrong 2.,nitiating play with other children3.8aving a vocabulary of at least 1))) words!.Asing short sentences to e;press independence #$%&!# 2yearold child uses short sentences to e;press independence and control' does not understand the concepts of right and wrong' may engage in solitary play and begin to  participate in parallel play' may initiate play with other children' and has a vocabulary up to 3)) words.D,-&#/-&10O&<nowledgeO4&$ursing 4rocess& #ssessment+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9Browth and +osby items and derived items > 2))' 2))0 by +osby' ,nc.' an affiliate of /lsevier ,nc. 122  est an  Development: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments(.,n planning nursing care for an 1=monthold child' the nurse should now that the  predominant developmental characteristic of children this age is&1.4arallel play2.4eer pressure3.+utilation an;iety!.,maginary playmates#$%&1During toddlerhood' the child begins to participate in parallel play' which is playing  beside rather than with another child. 4eer pressure is seen with the schoolage child. # fear of the preschool child is bodily harm. he preschool child may have imaginary  playmates.D,-&#/-&10O&<nowledgeO4&$ursing 4rocess& 4lanning+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9Browth and Development: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments.he nurse' in wor ing with children of this age' plans to allow a 0yearold boy who was admitted to the surgical center to have his tonsils removed to&1.4erform his own preoperative hygienic care2.8ave alone time to rela; before the procedure3.8andle the e@uipment when ta ing his blood pressure!.8ave access to ageappropriate magaines and pules for diversion#$%&34reschool children may cooperate if they are allowed to manipulate the e@uipment. #  preschooler is unable to ta e responsibility for his or her own preoperative hygienic care.5eaving the preschooler alone may increase the child*s an;iety. +againes and pules would be more appropriate activities for the older child. he preschool child li es to engage in pretend play' using their imagination and imitating adult behavior.D,-&#/-&1()O&ComprehensionO4&$ursing 4rocess& 4lanning+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9Browth and Development: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments=.# parent of a 3yearold boy states that she is concerned because he was potty trained long before hospitaliation but now refuses to use the toilet. What is the correct response  by the nurse?1.EFour son is probably feeling neglected' and you should ma e an effort to spend more time with him.G +osby items and derived items > 2))' 2))0 by +osby' ,nc.' an affiliate of /lsevier ,nc. 123  est an  2.Ehis is common behavior that is e;pressed when the hospitalied child is stressed or an;ious.G3.EFou may need to include discipline because children easily lose the ability to be toilet trained during hospitaliation.G!.EFour son was probably not ready to be potty trained' and you may want to continue the training for the ne;t ( months.G#$%&2During times of stress or illness' preschoolers may revert to bedwetting or thumbsuc ing and want the parent to feed' dress' and hold them. eassuring the parent that this is normal coping behavior may help alleviate their concern. everting to a prior level of functioning' such as a child who was potty trained now refusing to use the toilet' does notindicate the child is feeling neglected. he behavior demonstrates that the child is e;periencing stress and this is a coping behavior. Disciplining the child would not be a correct response. he child should be provided with e;periences he or she can master. %uch successes help the child to return to their prior level of independent functioning.everting to a prior level of functioning' such as a child who was potty trained now refusing to use the toilet' does not indicate the child was unready to be potty trained. he  behavior more li ely demonstrates that the child is e;periencing stress' and this is a coping behavior.D,-&#/-&1(1O&ComprehensionO4&$ursing 4rocess& #ssessment+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9Browth and Development: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific #ssessments.# ! 192yearold child is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort?1.E4lease try to not move your leg and that will ma e it feel better.G2.E,*ll give you a shot of medicine that will help ta e the pain away.G3.E,t*s o ay if you need to cry. Would you li e to hold your favorite doll?G!.EWould you li e to tell me now where you want me to give you your shot?G#$%&3elling the child it*s o ay to cry and hold a toy informs the child what they can do' and involves an ageappropriate familiar toy to provide comfort. elling the child not to movewhen they are in pain is unli ely to be effective. # preschool child may have difficulty in understanding the re@uest. elling the child they are going to get a shot may increase their an;iety' as they fear bodily harm. ,f a child is allowed to determine the site for administration of an inHection' specific sites should be offered as choices. 8owever' the nurse needs to avoid allowing procrastination by the child.D,-&#/-&1()O&ComprehensionO4&$ursing 4rocess& 4lanning+%C&$C5/67 test plan designation& 8ealth 4romotion and +aintenance9Browth and Development: 4hysiological ,ntegrity9eduction of is 4otential9%ystem %pecific +osby items and derived items > 2))' 2))0 by +osby' ,nc.' an affiliate of /lsevier ,nc. 12!

Chapter 002

Jul 23, 2017

Chapter 005

Jul 23, 2017
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