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 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.
Resentment toward the mother.
Anxiety reaction.
Regression.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale
Developing autonomy is a normal developmental milestone for toddlers. However, the behaviors described in the question (sitting quietly, sucking thumb, turning away) are more indicative of regression rather than autonomy.
Choice B rationale
Resentment toward the mother is not a typical developmental reaction for an 18-month-old toddler. The behaviors described are more indicative of regression due to the stress of hospitalization.
Choice C rationale
Anxiety reaction can occur in toddlers who are hospitalized, but the behaviors described (sitting quietly, sucking thumb, turning away) are more indicative of regression.
Choice D rationale
Regression is a common reaction in toddlers who are hospitalized. The behaviors described (sitting quietly, sucking thumb, turning away) are typical signs of regression, where the child reverts to earlier developmental behaviors as a coping mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Increasing the oxygen flow rate may help improve oxygen saturation, but it does not address the underlying issue of fluid overload and heart failure exacerbation.
Choice B rationale:
Administering an additional dose of furosemide may help reduce fluid overload, but it is not the most immediate action to improve the client’s respiratory status and comfort.
Choice C rationale:
Notifying the healthcare provider is important, but the nurse should first take immediate action to improve the client’s respiratory status and comfort.
Choice D rationale:
Repositioning the client to a high Fowler’s position is the most appropriate initial nursing action. This position helps improve lung expansion and reduces the work of breathing, providing immediate relief for the client experiencing dyspnea and respiratory distress.
Correct Answer is C
Explanation
The correct answer is C. Sit the child upright and apply pressure to the sides of the nose.
Choice A rationale
Keeping the child flat and applying pressure to the bridge of the nose is not effective for managing a nosebleed. The child should be in an upright position to reduce blood flow to the nose and prevent swallowing blood.
Choice B rationale
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended approach for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose.
Choice C rationale
Sitting the child upright and applying pressure to the sides of the nose is the correct action. This position helps to reduce blood flow to the nose and applying pressure helps to stop the bleeding.
Choice D rationale
Elevating the head of the bed slightly and applying pressure to the forehead is not effective for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose to stop the bleeding. .
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