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Health Promotion and Maintenance 1.A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits ... of tetanus antitoxin? It stimulates plasma cells directly. A high titer of antibodies is generated. It provides immediate active immunity. A long-lasting passive immunity is produced. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting. 2.A nurse is determining whether a 5-year-old child is displaying appropriate behaviors for this age. What developmental findings does the nurse expect? Select all that apply. Enjoys imitative play Engages in ritualistic games Makes up rules for a new game Asks for a pacifier when uncomfortable Plays near others quietly but not with them Imitating adults by playing adult roles in society is at its peak in children 5 years of age; activities are strongly identified with same-sex parent. A 5-year-old is able to negotiate and use make-believe to play. These children are able to follow some rules but may cheat to win. Older children in the middle childhood years need conformity and rituals, whether they play games or amass collections. Rules to games are fixed, unvarying, and rigid. Knowing the rules means belonging. The use of a pacifier for oral satisfaction is typical of infants. Parallel play occurs in children ages 2 to 3 years. 3.What is the most appropriate communication strategy for the nurse working with adolescents in a clinic in a large city health center? Relating on a peer level Using typical teenage language Establishing a relationship over time Having discussions in concrete terms Several meetings with an adolescent provide an opportunity to develop trust and establish a relationship. Relating on a peer level is unrealistic because the nurse is not an adolescent’s peer. Using teenage language is not necessary and may even impede the establishment of a relationship. It is not necessary to use concrete terms, because the adolescent is capable of abstract thought. 4.The nurse is examining different statements that represent the stages of psychosexual development, according to Sigmund Freud’s psychoanalytical model of personality development. Which statement indicates that the individual is aged between 6 to 12 years? The individual focuses on educational and social accomplishments. The individual tries to resolve prior sexual conflicts that have resurfaced. The individual realizes that the parent is something separate from the self. The individual fantasizes about the parent of the opposite sex as the first love interest. According to Sigmund Freud’s psychoanalytical model of personality development, an individual reaches the latency stage between 6 to 12 years of age. At this stage, the sexual urges of the oedipal stage are repressed and the individual channels them into socially acceptable productive activities. Therefore, the child focuses on educational and social accomplishments. When an individual reaches the genital stage, prior sexual conflicts resurface. He or she tries to resolve them in order to be able to begin an adult mature relationship. At the oral stage, which begins from birth and continues till 12 to 18 months, the infant is able to realize that the parent is something separate from the self. An individual between 3 to 6 years old is in the phallic or oedipal stage. At this stage, the child fantasizes about the parent of the opposite sex as the first love interest. Which of these features would the nurse state are exhibited by a preschooler? Temper tantrums Attempts to control situations Synchronization of moral skills Eagerness for formal education Learn to function independently Preschoolers refine the mastery of their bodies to function independently and eagerly await the beginning of formal education.When parents try to control the behavior of a toddler, it leads to temper tantrums and negative behavior. Toddlers get to know their abilities to control situations and seem pleased with it. School-aged children and adolescents refine and synchronize physical, psychosocial, cognitive, and moral skills to become accepted members of society. What important teaching strategies should the nurse take into consideration to bring a change in the client’s lifestyle? Select all that apply. Use written resources at an appropriate reading level. Practice active listening, and ask the client how he or she prefers to learn. Refrain from including family member in efforts to bring a change in the client’s lifestyle. Provide timelines for modification of eating and exercise lifestyle habits without consulting with the client. Start with identifying what information the client knows regarding health risks related to poor lifestyle choices. To bring a change in the client’s lifestyle, the nurse should use written resources at an appropriate reading level. The nurse should practice active listening and ask the client how he or she prefers to learn. The nurse should start by identifying what information the client knows regarding health risks related to poor lifestyle choices. The nurse should include family members to help bring changes in the client’s lifestyle. The nurse should provide timelines for modification of eating and exercise lifestyle habits after consulting with the client. 6.A parent expresses concern that the adolescent child is not ingesting enough calcium because of an allergy to milk. What alternative foods or liquids should the nurse suggest? Select all that apply. Cottage cheese Green leafy vegetables Black or baked beans Yogurt Oranges Salmon and sardines Green leafy vegetables, black and baked beans, oranges, and salmon and sardines are all good sources of calcium even though they do not contain milk or milk products. Cottage cheese and yogurt both contain milk and therefore must be eliminated. 9.A client asks a nurse about the most common problem associated with the use of an intrauterine device (IUD). What answer should the nurse provide? Perforation of the uterus Spontaneous device expulsion Discomfort associated with coitus Development of vaginal infections The IUD may cause irritability of the myometrium, inducing contraction of the uterus and expulsion of the device. Perforation of the uterus is a rare, rather than a common, occurrence. Clients do not report discomfort during coitus when an IUD is in place. Increased incidence of vaginal infections is not reported with the use of an IUD. 10.A couple interested in family planning asks the nurse about the cervical mucus method of family planning. The nurse explains that with this method the couple must avoid intercourse when and a few days after the cervical mucus is what? Clear and thick Yellow and thin Cloudy and viscid Clear and stretchable The cervical mucus is clear and stretchable (spinnbarkeit) at ovulation because of maximal estrogen stimulation. Clear, thick cervical mucus occurs after ovulation has occurred. Yellow, thin cervical mucus does not occur at any specific point during the menstrual cycle and may indicate an infection. The parents of a school-age child tell the nurse, "My child seems very hot or red in the face, has abdominal pain, and appears jittery." What does the nurse suggest as the reason for the child’s signs and symptoms? "The child is experiencing stress in some area of life." "The child is growing up and feels the need for autonomy." "The child may be eating mostly junk food out of the house." "The child may be staying up late at night to watch television." Appearing hot or red in the face and jittery, along with abdominal pain, indicates that the child is experiencing stress. The parents need to talk about any stressors that the child is experiencing and should encourage the use of effective problem-solving and coping skills. Staying up late at night and watching television may cause fatigue, but not abdominal pain or jitteriness. The school-age child does not seek autonomy and shares most things with the family. Eating junk food out of the house may result in obesity or unhealthy eating habits. 2.What nursing intervention best meets a major developmental need of a newborn in the immediate postoperative period? Giving a pacifier to the infant Putting a mobile over the infant's crib Providing the infant with a soft, cuddly toy Warming the infant's formula before feeding Sucking meets oral needs, which are primary during infancy. An infant a few days old is too young to focus well on a mobile; in addition, the newborn will be placed in a side-lying position after surgery and therefore would not be able to see a mobile. A newborn is not developmentally capable of enjoying a soft, cuddly toy. Warming the infant's formula before feeding does not satisfy a developmental need. 3.A nurse is caring for a hospitalized school-aged child. What development-related activity is most important for the nurse to encourage? Family contact Peer interaction Therapeutic play Academic studies School-aged children have a need to be successful in school; this will help ensure that the child keeps up with the work being presented in class. Although contact with family is important, the school-aged child is beginning to move away from the family and into other realms. Although peer and social interactions [Show More]

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