160: Comprehensive review

The developmental task of the school-aged period, according to Erikson, is gaining a sense of:

• autonomy versus shame.

• independence versus dependence.

• industry versus inferiority.

• identity versus failure.

Answer explanation

The school-age years, according to Erickson, are the stage of industry versus inferiority. The developmental stage helps increase the child's sense of self worth.

A nurse is caring for a hospitalized 10-year-old child. What would be an appropriate activity for this child to meet the developmental tasks of this age group?

• Participating in a craft project

• Playing with a jack-in-the-box

• Playing with blocks

• Writing letters to friends

Answer explanation

During this stage, the child is interested in how things are made and run. The child learns to manipulate concrete objects. The child likes engaging in meaningful projects and seeing them through to completion. Playing jack-in-the-box and blocks are for much younger children. If anything, the child would be texting back and forth with friends, not writing a letter. Piaget's Concrete operational stage

A nurse is applying a cast to a 12-year-old boy with a simple fracture of the radius in the arm. What is most important for the nurse to do when she has finished applying the cast?

• Assess the fingers for warmth, pain, and function

• Apply a tube of stockinette over the cast

• Cut a window in the cast over the wrist

• X-ray the cast to make sure the bones are aligned properly

Answer explanation

application of a cast to be certain a compartment syndrome is not developing. 6 P's: pain, poikilothermia, paresthesias, paralysis, pulses, pallor

The nurse is caring for a child who fractured the arm in an accident. A cast has been applied to the child's right arm. Which action(s) should the nurse implement? Select all that apply.

• Monitor the color of the nail beds in the right hand.

• Document any signs of pain.

• Wear a protective gown when moving the child's arm.

• Check capillary refill time in the both arms.

• Wear sterile gloves when removing or touching the cast.

Answer explanation

The most important function for the nurse in caring for a child in a cast is frequent neurovascular checks. The nurse should monitor for increased pain and edema, a pale or blue color to the extremities, skin coolness, numbness or tingling, poor capillary refill, and decreased pulse strength. Increased pain, especially unrelieved with pain medications, can indicate serious complications such as compartment syndrome

A nurse is caring for a newborn born after a prolonged and difficult labor. What nursing intervention should the nurse perform when assessing for trauma and birth injuries in the newborn?

• Examine the newborn’s skin for cyanosis.

• Be alert for signs of apathy and listlessness.

• Assess the newborn for any temperature instability.

• Note any absence of or decrease in deep tendon reflexes.

Answer explanation

Noting any absence of or decrease in deep tendon reflexes is a nursing intervention when assessing a newborn with a risk of trauma. The nurse should examine the skin for cyanosis, should be alert for signs of apathy and listlessness, and should assess for any temperature instability when caring for a newborn born to a mother with diabetes. These interventions are not required to assess for trauma or birth injuries in a newborn.

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

• hypothermia

• impaired parenting

• deficient fluid volume

• risk for infection

Answer explanation

The newborn's heart rate is slightly below the accepted range of 120 to 160 beats per minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.7℉ (36.5 to 37.6℃). Therefore, the priority problem area is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is deficient fluid volume or a risk for infection.

Tags

NGSS.HS-LS1-3

The nurse is caring for a 3-year-old client being treated for severe status asthmaticus. After comparing clinical manifestations with laboratory results (reported below), a nurse determines evidence that this client has progressed to which condition?

• respiratory alkalosis

• metabolic acidosis

• respiratory acidosis

• metabolic alkalosis

Answer explanation

A pH less than 7.35 and a PaCO₂ greater than 45 mm Hg (6.0 kPa) indicate respiratory acidosis. Status asthmaticus is a medical emergency that's characterized by respiratory distress. At first, the client hyperventilates; then respiratory alkalosis occurs, followed by metabolic acidosis. If treatment is ineffective or has not begun, symptoms can progress to hypoventilation and respiratory acidosis, both of which are life-threatening.

The nurse is aware that the major role of the kidneys in regulating acid–base balance is to increase the production of which chemical component?

• H₂CO₃

• HCl

• HCO₃–

• H⁺

Answer explanation

The kidneys play a critical role in maintaining acid–base balance. They accomplish this through the reabsorption of HCO₃–, regulation of H+ secretion, and generation of new HCO₃–. The hydrogen/bicarbonate exchange system regulates pH through the secretion of excess H+ and reabsorption of HCO₃– by the renal tubules. Bicarbonate is freely filtered in the glomerulus and reabsorbed or reclaimed in the tubules. Each HCO₃– that is reclaimed requires the secretion of an H+. H₂CO₃ is a weak acid. HCl is found in gastric fluid. The kidneys would eliminate, not increase, production of H ion.

A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects to prepare the client for which diagnostic study?

• genetic testing

• cystoscopy

• myelography

• colonoscopy with biopsy

Answer explanation

Crohn's disease is an inflammatory bowel disorder characterized by inflammation, ulceration, and edema of the bowel wall (typically involving the terminal ileum). Colonoscopy with biopsy are the primary procedures used to establish the diagnosis; a barium enema also may be indicated. Although genetics may play a role in Crohn's disease, genetic testing isn't part of the diagnostic workup. Clients may also have perianal skin tags and/or fissures

The nurse is caring for a 77-year-old patient diagnosed with Crohn's disease. What would be especially important to monitor this patient for?

• Pain

• Fluid overload

• Fatigue

• Dehydration

Answer explanation

Elderly patients can become dehydrated quickly and develop low potassium levels (i.e., hypokalemia) as a result of diarrhea. The nurse observes for clinical manifestations of muscle weakness, dysrhythmias, or decreased peristaltic motility that may lead to paralytic ileus. All options would be important to monitor, but especially important is monitoring for dehydration.