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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. A story book about a child who has diabetes. While providing information about diabetes through a storybook may be beneficial for the child's understanding of the condition, it may not directly address the distress experienced after an insulin injection. This option focuses more on education rather than immediate coping with the injection-related distress.

B. A needleless syringe and a doll. This is the correct choice. Providing a needleless syringe and a doll allows the child to engage in pretend play and role-play scenarios related to the insulin injection experience. Through play, the child can express their feelings, fears, and experiences in a safe and non-threatening environment. This type of play activity can help the child gain a sense of control, familiarity, and mastery over the situation, thereby reducing distress and anxiety associated with future injections.

C. A period of play in the playroom. While engaging in play in the playroom may offer the child opportunities for distraction and enjoyment, it may not specifically address the distress experienced after an insulin injection. The effectiveness of this option in helping the child cope with the injection-related distress may depend on the specific activities available in the playroom and the child's preferences.

D. A video game. Playing a video game may provide the child with distraction and entertainment, but it may not directly address the distress experienced after an insulin injection. Additionally, screen time may not be suitable for every child, and the therapeutic benefits of video games in this context may vary.

A. Before auscultating the chest and abdomen B. Before examining the head and neck C. At the end D. At the beginning

Correct Answer is C

Explanation

A. Before auscultating the chest and abdomen: Examining the tympanic membrane before auscultating the chest and abdomen is not ideal. It's important to follow a systematic approach in physical examination, typically starting with less invasive assessments before progressing to more invasive or uncomfortable ones. Therefore, examining the tympanic membrane before auscultating the chest and abdomen may disrupt this systematic approach.

B. Before examining the head and neck: Similarly, examining the tympanic membrane before examining the head and neck is not appropriate. The head and neck examination typically includes less invasive assessments such as observing the child's appearance, palpating the fontanelles, and inspecting the scalp, face, and neck. The tympanic membrane examination, which involves using an otoscope, is more invasive and should be performed later in the examination.

C. At the end: This is the correct choice. Examining the tympanic membrane at the end of the physical examination allows the nurse to establish rapport with the child and gain their cooperation before performing a potentially uncomfortable or intrusive examination of the ears. Starting with less invasive and more familiar assessments, such as observing the child's general appearance and behavior, auscultating the chest and abdomen, and examining the head and neck, can help build trust and reduce anxiety before proceeding to more specific assessments, such as otoscopy.

D. At the beginning: Examining the tympanic membrane at the beginning of the physical examination may cause the child distress and anxiety, potentially making the rest of the examination more challenging. It's preferable to perform less invasive assessments first to help the child become more comfortable and cooperative before proceeding to more invasive examinations like otoscopy. Therefore, examining the tympanic membrane at the beginning is not recommended.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

Correct Answer is B

Explanation

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane??

Correct Answer is C

Explanation

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?

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler?

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

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 community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?

A nurse in a PACU is admitting a client who is postoperative following ad from the waist down. Which of the following statements by the client take to prevent aspiration?

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?