At the well-child clinic the nurse notices that a 26-month-old boy is displaying negative behavior
His mother relates that he refuses to have anything to do with toilet training and often shouts "no!"
when given direction.
His mother asks what might be the matter with her son. On the basis of
knowledge of growth and development, the nurse should reply
a. "He is behaving normally for his age. He is striving for independence.".
b. "He needs firmer control. He should be scolded when he tells you ‘no' and is
defiant.".
c. "I suspect he has a serious developmental problem because most children are
toilet trained by the age of 2 years.".
d. "He seems to be developing some undesirable attitudes. A child psychologist
might be able to help you develop a remedial plan.".
ANS: A
Options B, C, and D all indicate the child's behavior is abnormal when, in fact, this behavior is
typical of a child around the age of 2 years whose developmental task is to develop autonomy.
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A patient arrives at the ambulatory clinic for a routine physical. The nurse inquires about the patient's sleep pattern. The patient has a history of sleep pattern disturbances
The nurse evaluates that the patient is sleeping better when he or she states which of the following? a. "I don't take melatonin as frequently." b. "I increased my alcohol consumption before bedtime." c. "I decreased my activity level." d. "I take more daytime power naps."
The nurse notes a venous ulcer on the client's left ankle. What additional assessment finding does the nurse expect in this client?
a. Absence of hair on the left lower extremity b. Skin surrounding the ulcer mottled but blanchable c. Brownish discoloration of the lower extremity d. Cold and gray-blue lower extremity
A nurse is preparing to administer a sponge bath to reduce fever in a patient. Which of the following is the most appropriate action to take?
1. Lower the temperature of the room to aid in reducing the patient's body temperature. 2. Place ice in a bowl of water so that it is cold enough to have the desired effect. 3. Assess the patient's temperature to have a baseline. 4. Plan to provide care to other patients after applying moist cloths to this patient's axilla and groin.
In the transactional model of stress/adaptation, a nurse observes that secondary appraisal takes place when an individual judges an event to be:
A) Benign. B) Irrelevant. C) Challenging. D) Pleasurable.