A nurse is caring for an 18-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 cornerof 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?
An anxiety reaction
Regression
Resentment toward the mother
Developing autonomy
The Correct Answer is A
A. An anxiety reaction: The toddler's behavior of sitting quietly, sucking her thumb, and turning away from the nurse when approached after her mother leaves the room suggests anxiety. These
behaviors are common signs of distress or discomfort in young children, especially when separated from their primary attachment figure (in this case, the mother).
B. Regression: Regression involves reverting to earlier, more immature behaviors in response to stress or discomfort. While thumb sucking can be considered a form of regression, the behavior observed in this scenario is more indicative of anxiety rather than a broader regression in
developmental milestones.
C. Resentment toward the mother: There is no evidence in the scenario to suggest that the toddler is expressing resentment toward the mother. The behaviors observed are more likely related to
the child's emotional response to separation and hospitalization.
D. Developing autonomy: Developing autonomy typically involves asserting independence and exploring one's environment. The behaviors observed in the scenario are more indicative of anxiety and distress rather than autonomous behavior.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Can you stand very still while I feel how warm you are?": Toddlers may have difficulty understanding abstract requests or instructions. Asking a toddler to stand still to feel warmth may not effectively communicate the purpose of the assessment and may lead to confusion or
resistance.
B. "I am going to listen to your heart.": This statement provides clear, simple language that the toddler can understand. It prepares the child for the assessment and helps establish trust and cooperation.
C. "Can I listen to your lungs?": While this statement is appropriate for assessing respiratory sounds, it may not be as clear or specific as stating the intention to listen to the heart. Toddlers may not understand the term "lungs" as readily as "heart."
D. "I am going to take your blood pressure now.": This statement may cause anxiety or fear in the toddler, especially if they are unfamiliar with the procedure. It is important to prepare the child for each aspect of the assessment in a developmentally appropriate manner.
Correct Answer is B
Explanation
A. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016: While diabetes insipidus requires monitoring and management, a urine specific gravity of 1.016 alone does not indicate acute distress or an emergency situation. The child may need adjustments in fluid intake or medication, but this can typically be addressed in a less urgent manner.
B. A 10-year-old child who has sickle cell anemia who reports severe chest pain: Severe chest pain in a child with sickle cell anemia could indicate a vaso-occlusive crisis affecting the chest, which is potentially life-threatening. Prompt assessment and intervention are necessary to
manage the pain and prevent complications, including acute chest syndrome or respiratory compromise.
C. A 1-year-old toddler who has roseola and a temperature of 39°C (102.2°F): Roseola is typically a benign viral illness characterized by fever and a rash. While a fever in a young child
requires monitoring and symptomatic management, it is not usually considered an emergency unless accompanied by other concerning symptoms such as dehydration or respiratory distress.
D. A 4-year-old child who has asthma and a PCO2 of 37 mm: While asthma exacerbations can be serious, a PCO2 level of 37 mm indicates normal carbon dioxide levels, which do not suggest acute respiratory distress or impending respiratory failure. However, if the child is experiencing severe respiratory distress, cyanosis, or altered mental status, immediate assessment and
intervention would be warranted.
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