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 D

Explanation

A. Closed posterior fontanel

By 6 months of age, the posterior fontanel typically closes. The posterior fontanel usually closes between 2 and 4 months of age. Therefore, a closed posterior fontanel is an expected finding at 6 months.

B. Lateral incisors

The eruption of lateral incisors typically occurs between 8 and 12 months of age. At 6 months, it is not expected for the infant to have erupted lateral incisors. Therefore, this finding would not be typical during a well-child visit at this age.

C. Uses thumb and index fingers in a pincer grasp

The development of the pincer grasp, where the infant can pick up small objects using the thumb and index finger, typically occurs around 9 to 12 months of age. While some infants may start to develop this skill around 6 months, it is more commonly seen later in the first year. Therefore, it is not a definitive finding at 6 months.

D. Sitting steadily without support

By 6 months of age, most infants can sit steadily without support. This is considered a developmental milestone that typically occurs around 6 months. Therefore, sitting steadily without support is an expected finding during a well-child visit at this age.

A. Providing support for family and friends following a suicide B. Recognizing the warning signs of suicide C. Performing life-saving measures following a suicide attempt D. Identifying individuals who are at higher risk for attempting suicide

Correct Answer is C

Explanation

A. Providing support for family and friends following a suicide:

Providing support for family and friends following a suicide is an example of a tertiary intervention. Tertiary interventions focus on providing support, counseling, and resources to individuals affected by suicide after the event has occurred, aiming to prevent further emotional distress, promote healing, and reduce the risk of additional suicides in the community.

B. Recognizing the warning signs of suicide:

Recognizing the warning signs of suicide is an example of a primary intervention. Primary interventions aim to prevent suicide by identifying individuals at risk and intervening before a suicide attempt occurs. Educating healthcare professionals and the community about the warning signs of suicide is crucial for early identification and intervention.

C. Performing life-saving measures following a suicide attempt:

This is an example of a secondary intervention. Secondary interventions involve actions taken after the occurrence of a suicide attempt or completed suicide to prevent further harm or loss of life. Performing life-saving measures, such as cardiopulmonary resuscitation (CPR) or providing emergency medical care, falls under secondary interventions because it occurs after the suicide attempt to mitigate the immediate physical consequences.

D. Identifying individuals who are at higher risk for attempting suicide:

Identifying individuals who are at higher risk for attempting suicide is also an example of a primary intervention. This involves screening, assessment, and risk evaluation to identify individuals with risk factors and warning signs of suicide, allowing for targeted interventions, support, and prevention strategies to be implemented before a suicide attempt occurs.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary Intervention?

Correct Answer is C

Explanation

A nurse is caring for a toddler who has acute laryngotracheobonchitis after a repair of an intussusception. Which of the indicates that the treatment has been effective?

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 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?

During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

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??

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 is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

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?