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

An anxiety reaction

Resentment toward the mother

Regression

Answer and Explanation

The Correct Answer is B

These behaviors suggest that the child is experiencing distress or discomfort in response to the separation from the mother and the hospital environment.

Anxiety reactions are common in toddlers who are hospitalized or experience separation from their primary caregivers. It is a normal response to unfamiliar and potentially stressful situations. Toddlers at this age are still developing a sense of security and trust in their environment, and being in the hospital can disrupt their routine and comfort.

It is important for the nurse to provide a calm and supportive environment for the toddler, offering reassurance and comfort. The nurse can engage in activities that promote a sense of security and provide opportunities for the toddler to express their emotions and fears, such as through play or comforting rituals.

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Correct Answer is C

Explanation

A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.

B.Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.

C.Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible.If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.

D.If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.

A. Eyes wide open B. Furrowed brow C. Decreased muscle tone D. Dry hands and feet

Correct Answer is B

Explanation

Furrowing of the brow is often associated with discomfort or distress in infants. Other signs of pain in infants can include crying, irritability, increased heart rate, increased respiratory rate, and changes in sleep and feeding patterns. The eyes wide open, decreased muscle tone, and dry hands and feet are not specific indicators of pain and may have other explanations or may be within normal variations for an infant.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 nurse is caring for a 6-month-old infant. Which of the following findings indicates to the nurse that the infant may be experiencing pain?

Correct Answer is B

Explanation

A nurse working in a pediatric clinic recognizes the three most common toxins in pediatric care?

Which foods would the nurse recommend to the mother of a 2-year-old with iron deficiency anemia?

A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

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 in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching?

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 assessing a 6-month-old infant. Which of the following findings should the nurse report to the provider?

A nurse is administering vaccines at a county health immunization clinic. Which of the following clients should the nurse plan to administer the meningococcal conjugate (MCV4) vaccine?