- The nurse is reinforcing teaching with a new mother about preventing sudden infant death syndrome (SIDS). Which statement by the mother indicates a correct understanding of the teaching?
Answer: "I will always place my baby on their back to sleep."
The single most effective action to reduce the risk of SIDS is to place infants on their back for all sleep times. The crib should be free of soft objects like bumpers, blankets, and toys. Co-sleeping (bed-sharing) is not recommended as it increases the risk of suffocation. Prone (stomach) sleeping is strongly associated with an increased risk of SIDS.
- The nurse is reinforcing teaching with a 45-year-old client about routine health screenings. Which screening should the nurse emphasize as being particularly important for this developmental stage?
Answer: Blood pressure and cholesterol screening.
Middle adulthood is a time when the risk for chronic diseases such as hypertension and hyperlipidemia increases. Therefore, routine screening for blood pressure and cholesterol is a key health promotion activity. Scoliosis screening is done during adolescence. Developmental milestone screening is for infants and children. While hearing changes can begin in middle age, routine screening for presbycusis is more commonly associated with older adulthood.
- The nurse is providing care to a 50-year-old client who is mentoring younger colleagues at work and volunteering at a local youth center. The nurse recognizes that these activities are fulfilling which of Erikson's developmental tasks?
Answer: Generativity
Middle adulthood (approximately 40-65 years) is characterized by the psychosocial task of Generativity vs. Stagnation. Generativity involves contributing to society and guiding the next generation, often through work, community involvement, and raising children. These activities are prime examples of generativity. Intimacy is for young adults, Industry for school-age children, and Identity for adolescents.
- The nurse is collecting data on a 2-month-old infant. The nurse notes that when a loud noise occurs, the infant abducts and extends the arms, and the fingers fan out. Which action should the nurse take?
Answer: Document the finding as a normal Moro reflex.
The behavior described is the Moro (startle) reflex, which is a normal primitive reflex present at birth. It typically disappears between 3 and 6 months of age. Its presence at 2 months is an expected finding and should be documented as such. There is no need to report this normal finding, and it does not indicate seizure activity.
- The nurse is caring for a 2-year-old child who insists on feeding herself despite making a mess and becomes upset when the parent intervenes to help. According to Erikson, which developmental task does this behavior reflect?
Answer: Autonomy vs. shame and doubt.
Autonomy vs. shame and doubt is Erikson's second stage, occurring from approximately 1 to 3 years. Toddlers strive to establish independence and self-control, as demonstrated by insisting on self-feeding and resisting parental help. Supporting autonomy while maintaining safe limits promotes healthy development. Trust vs. mistrust is the infant stage focused on having needs met consistently by caregivers. Initiative vs. guilt is the preschool stage in which children take purposeful initiative in play and social settings. Industry vs. inferiority is the school-age stage focused on developing skills and competence through tasks and learning.
- The nurse is preparing to administer an oral medication to a 5-year-old child. Which approach is most developmentally appropriate?
Answer: Letting the child choose between taking the medicine from a cup or an oral syringe.
Giving a preschooler a simple, appropriate choice helps them feel a sense of control and promotes cooperation, aligning with their developmental stage of initiative. Deceiving a child by calling medicine candy can erode trust. Mixing medication in a large volume like a bottle of milk risks the child not finishing it and receiving an incomplete dose. Using threats is inappropriate and can increase fear and anxiety.
- The nurse is reinforcing teaching with a 75-year-old client about expected age-related changes. Which statement by the client indicates that further teaching is needed?
Answer: "It's normal to feel thirsty all the time at my age."
The thirst sensation diminishes with age, increasing the risk of dehydration. Constant thirst (polydipsia) is not a normal finding and could indicate an underlying health issue, such as hyperglycemia, requiring further investigation. Using night lights, experiencing changes in taste, and having altered sleep patterns are all common, expected changes in older adulthood.
- An 82-year-old client in a long-term care facility frequently talks about past accomplishments and experiences. What is the nurse's most therapeutic action?
Answer: Sit with the client and listen to the stories.
Older adults are in the developmental stage of Ego Integrity vs. Despair. Reminiscence, or life review, is a normal and therapeutic process that helps them find meaning in their lives and achieve a sense of ego integrity. The nurse should facilitate this process by actively listening. Redirecting the conversation or suggesting they are living in the past is non-therapeutic and dismisses the client's needs. Limiting the time for this important task is also inappropriate.
- An 8-year-old child is proud of learning to ride a bicycle without training wheels and eagerly helps a parent build a birdhouse. Which Erikson stage does this behavior most reflect?
Answer: Industry vs. inferiority.
Industry vs. inferiority is Erikson's fourth stage, occurring from approximately 6 to 12 years. School-age children focus on acquiring new skills, completing tasks successfully, and being productive. Pride in mastering bicycle riding and completing projects reflects the industry component of this stage. When children fail to master skills or are compared unfavorably to peers, they may develop a sense of inferiority. Initiative vs. guilt is the preschool stage focused on goal-directed play. Identity vs. role confusion is the adolescent stage involving the development of personal identity. Autonomy vs. shame and doubt is the toddler stage focused on independence.
- The nurse is collecting data about the language development of a 24-month-old child. Which finding would be an expected milestone for this age?
Answer: Using two-to-three word sentences.
By 24 months (2 years), a toddler is expected to have a vocabulary of about 300 words and be able to speak in two-to-three word sentences. Speaking in complex sentences is characteristic of a preschool or school-aged child. Saying only "mama" and "dada" or having a vocabulary of less than 10 words would be expected at a much younger age (around 12 months) and would be a developmental concern at 24 months.
- The LPN/VN is collecting data from a 70-year-old female client during a routine visit. Which musculoskeletal change should the nurse recognize as a normal finding associated with aging?
Answer: Decreased bone density with increased risk of fracture.
Decreased bone density is a normal part of aging, particularly in postmenopausal women due to declining estrogen levels. This increases the risk of fractures, most commonly involving the hip, vertebrae, and wrist. When bone loss reaches diagnostic thresholds, it is classified as osteopenia or osteoporosis. Bone density decreases rather than increases with aging, as calcium absorption declines over time. Skeletal muscle mass and strength decline with aging in a process called sarcopenia, not hypertrophy. Tendons and ligaments become less flexible and more prone to injury with age, not more flexible.
- During a home visit, the LPN/VN observes two 2-year-old children playing in the same room with similar toys but not interacting with each other or sharing a common goal. The nurse correctly identifies this as which type of play?
Answer: Parallel play.
Parallel play is the developmentally expected form of play for toddlers at approximately 2 years of age. Children play alongside each other with similar materials but do not engage directly or share a goal. This is a normal toddler behavior and precedes more interactive forms of play. Cooperative play involves organized group activity with shared goals and assigned roles and develops during the preschool and school-age years. Associative play involves children interacting and sharing materials without an organized common goal and develops in the later preschool period. Solitary play occurs when a child plays entirely alone, separate from other children, which is the typical pattern of infants.
- Which Erikson stage is associated with the developmental task of establishing trust through consistent and responsive caregiving?
Answer: Trust vs. mistrust.
Trust vs. mistrust is Erikson's first psychosocial stage, occurring from birth to approximately 18 months. When caregivers consistently meet the infant's needs for food, comfort, and stimulation, the infant develops a sense of trust. Failure to meet needs results in mistrust. Autonomy vs. shame and doubt is the toddler stage (1 to 3 years) focused on developing independence. Industry vs. inferiority occurs during school age (6 to 12 years) and centers on competence through skill mastery. Initiative vs. guilt is the preschool stage (3 to 6 years) involving learning to take purposeful action without overstepping boundaries.
- A 68-year-old client is admitted to the hospital. When collecting data, the nurse notes the client has decreased skin turgor and dry mucous membranes. The client states, "I don't feel thirsty very often." The nurse recognizes this is a common issue because of what age-related change?
Answer: Diminished thirst sensation.
Older adults have a diminished thirst sensation, which puts them at a higher risk for dehydration. The data collected (decreased skin turgor, dry mucous membranes) and the client's statement support this. The glomerular filtration rate and total body water content decrease with age, and skin elasticity lessens, none of which would explain the lack of thirst.
- A 16-year-old client is recovering from an appendectomy. To support the client's psychosocial needs, what is the nurse's most appropriate action?
Answer: Allow the client's friends to visit during visiting hours.
Adolescents are in Erikson's stage of Identity vs. Role Confusion. Peer relationships are critically important for developing identity. Allowing friends to visit provides social support and normalcy. Parents should be involved, but the adolescent should be encouraged to participate in decisions. Restricting peer contact can lead to feelings of isolation. While rest is important, dismissing concerns about school ignores a central part of the adolescent's life.
- The nurse is providing care for a 14-year-old client who is concerned about a recent acne breakout. Which response by the nurse is most therapeutic?
Answer: "It's very common for teenagers to be concerned about their appearance."
Adolescents are highly focused on their body image and peer acceptance as part of their identity development. This response validates the client's feelings and normalizes their concern, which opens the door for further communication and teaching. Offering false reassurance (B), being dismissive (C), or giving unsolicited advice (D) are all non-therapeutic communication techniques.
- An older adult client reports difficulty reading a restaurant menu and needing to hold printed material farther away to see the words clearly. The LPN/VN recognizes this as a normal age-related change. Which term describes this condition?
Answer: Presbyopia.
Presbyopia is the normal age-related loss of near-vision focusing ability, caused by decreased elasticity of the eye's lens. It typically becomes noticeable after age 40 and is characterized by difficulty reading at a normal distance, requiring printed material to be held farther away. Cataracts involve clouding of the lens, causing blurred or foggy vision overall, and are a pathological condition rather than a universal aging change. Glaucoma results from increased intraocular pressure affecting peripheral vision and is not the cause of near-vision difficulty. Macular degeneration affects central vision through retinal changes and is a pathological condition, not a normal physiological change of aging.
- During a developmental screening, the LPN/VN is collecting data on a 2-year-old child's language development. Which language milestone would be expected for a typically developing 2-year-old?
Answer: Using two-word phrases such as 'more milk' or 'daddy go.'
By age 2, a typically developing toddler should use two-word phrases to communicate and have a vocabulary of approximately 50 words. Using complete five- to six-word sentences with proper grammar is typical of a 4-year-old and would indicate advanced development for a 2-year-old. Having a vocabulary limited to a few familiar words like 'mama' or 'dada' is expected by 12 months; limited vocabulary at age 2 warrants reporting to the provider. Using three- to four-word sentences and asking 'why' questions is typical of a 3-year-old. The LPN/VN collects this data during screening and reports concerns to the provider.
- The nurse is reinforcing teaching with the parents of a toddler about nutrition. Which statement indicates a correct understanding of a toddler's eating habits?
Answer: "My child's appetite might vary from day to day, and that can be normal."
Toddlers often experience physiologic anorexia and have fluctuating appetites, which is a normal developmental finding. Forcing a child to eat can lead to power struggles and unhealthy eating habits. While variety is good, toddlers often prefer familiar foods (food jags) and can be overwhelmed by too many new choices at once. Finger foods are developmentally appropriate and help promote autonomy, as long as they are cut into safe sizes.
- A 4-year-old child is hospitalized for a minor procedure. Which nursing action best supports the child's psychosocial development according to Erikson?
Answer: Allowing the child to place the bandage on a doll first.
Preschoolers are in the stage of Initiative vs. Guilt. Engaging in therapeutic play, such as placing a bandage on a doll, allows the child to take initiative, understand the procedure in a non-threatening way, and feel a sense of control. Using medical terms is inappropriate for this age. The presence of parents is supportive. Performing all care for the child can lead to feelings of guilt and loss of initiative.
