A nurse is caring for an 11-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions?

Developing autonomy

Regression

Resentment toward the mother

An anxiety reaction

Answer and Explanation

The Correct Answer is B

Incorrect:

A. Developing autonomy:

Rationale: Developing autonomy typically involves a toddler's exploration of their environment and assertion of independence. While seeking comfort in familiar behaviors like thumb-sucking can be a part of autonomy development, the behavior described in the scenario is more indicative of regression, which involves returning to earlier, more infantile behaviors rather than progressing towards independence.

B. Regression:

Rationale: Regression refers to reverting to behaviors characteristic of an earlier stage of development. In this scenario, the toddler's behavior of sitting quietly in the corner of the crib and sucking her thumb, as well as turning away from the nurse, suggests a regression to earlier comforting behaviors that are typical of younger infants. This regression may be a response to the stress and anxiety of being hospitalized and separated from the mother, seeking comfort in familiar behaviors.

C. Resentment toward the mother:

Rationale: There is no evidence in the scenario to suggest resentment toward the mother. The toddler's behavior of seeking comfort in thumb-sucking and turning away from the nurse is more indicative of distress or regression in response to the hospitalization and separation from the mother rather than directed resentment toward her.

D. An anxiety reaction:

Rationale: The toddler's behavior of sitting quietly in the corner of the crib, sucking her thumb, and turning away from the nurse suggests a response to stress or anxiety rather than an anxiety reaction per se. While anxiety may be a component of the toddler's emotional state, the behavior aligns more closely with regression as a coping mechanism in response to the stressors of hospitalization and separation from the mother.

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Correct Answer is C

Explanation

A. Expressive affect: Individuals with autism spectrum disorder (ASD) often have difficulty expressing their emotions in a typical manner. They may display a restricted range of facial expressions or have difficulty conveying emotions through facial expressions and gestures. However, "expressive affect" typically refers to the appropriate display of emotions, which may not be characteristic of ASD.

B. Ambivalence: Ambivalence refers to conflicting feelings or attitudes about a situation or person. While individuals with ASD may experience a range of emotions, including ambivalence, it is not a specific characteristic associated with the disorder. Ambivalence is a common human experience and may occur in individuals with or without ASD.

C. Echolalia: Echolalia is a common communication characteristic observed in individuals with ASD. It involves the repetition or echoing of words or phrases spoken by others. This behavior may occur immediately after hearing the words or phrases (immediate echolalia) or may be delayed. Echolalia can serve various functions, including communication, self-regulation, or expression of anxiety.

D. Associative looseness: Associative looseness is a thought disorder characterized by a lack of logical connection between thoughts and ideas. It is typically associated with conditions such as schizophrenia rather than ASD. Individuals with ASD may exhibit difficulties with social communication, including challenges in maintaining conversations or understanding social cues, but this is different from the disorganized thinking observed in associative looseness.

A. Skin integrity B. Blood pressure C. Respiratory rate D. Body weight

Correct Answer is D

Explanation

A. Skin integrity: Skin integrity can be an indicator of dehydration, as dehydrated skin may appear dry and lack elasticity. However, skin turgor is not the most reliable indicator of fluid loss because it can be influenced by factors such as age and overall health. For example, infants and older adults may have decreased skin turgor due to a loss of skin elasticity, even if they are adequately hydrated.

B. Blood pressure: Blood pressure can decrease with significant fluid loss because there is less fluid volume to fill the arteries, leading to a drop in blood pressure. However, blood pressure is not the most reliable indicator of fluid loss because it can be influenced by many other factors, such as heart function and vascular resistance. Additionally, blood pressure may not change significantly until severe dehydration occurs.

C. Respiratory rate: An increased respiratory rate can be a sign of dehydration because the body may try to compensate for fluid loss by increasing the respiratory rate to deliver more oxygen to the tissues. However, an increased respiratory rate is a nonspecific symptom that can be associated with many other conditions, such as fever, pain, or lung disease. Therefore, it is not the most reliable indicator of fluid loss.

D. Body weight: Body weight is the most reliable indicator of fluid loss. This is because water makes up a significant portion of body weight, so a decrease in body weight is a direct indication of fluid loss. In infants, a rapid change in weight is often the first sign of fluid imbalance because they have a higher percentage of body water and a higher metabolic rate compared to adults. A 5% weight loss is considered mild dehydration, 10% is moderate, and 15% or more is severe. Therefore, regular monitoring of an infant’s weight is crucial when assessing for dehydration.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Correct Answer is D

Explanation

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages?

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development?

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture. Which one of the following should the nurse include in the plan of care?

A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply)

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?