NCLEX Psychological & Developmental Variables Flashcards
A mother complains that her 13-year-old has started to grow rapidly, and asks the nurse if this is normal and how long it will last. The best nursing response is:
- ) “This is unusual at this age, and a physician should be contacted.”
- ) “This is normal, but will only last a few months.”
- ) “This is normal and can last until about age 20.”
- ) “This is normal, but growth should be completed by about age 15 or 16.”
3.) “This is normal and can last until about age 20.”
[Growth rate is normally rapid during the adolescent years from ages 12-20. It can be expected to occur throughout this entire time span, not just for a few months or years.]
A 21-year-old who has just graduated from college has had a serious automobile accident and faces many months of hospitalization and rehabilitation. The nurse, in planning care, recognizes that according to Havighurst, this client may delay or have difficulty with successful accomplishment of which developmental task?
- ) Selecting a mate and getting started in an occupation
- ) Exhibiting socially responsible behavior and developing an ethical system of behavior
- ) Developing a conscience and developing appropriate masculine or feminine role
- ) Selecting an occupation and developing intellectual skills necessary for civic competence
1.) Selecting a mate and getting started in an occupation
Havighurst identifies two developmental tasks of early adulthood: selecting a mate and getting started in an occupation. Exhibiting socially responsible behavior, developing an ethical system of behavior, selecting an occupation, and developing intellectual skills necessary for civic competence are tasks of adolescence, and should already have been accomplished. Developing a conscience and developing appropriate masculine or feminine social roles are tasks of middle childhood, and also should already have been accomplished.
A mother is frustrated because her 2½-year-old is not toilet trained and will not use the potty when placed on it. What suggestion by the nurse is most appropriate?
- ) Do not let the child off the potty until stool or urine is evacuated.
- ) Do not try to toilet-train the child, as it is too early.
- ) Give the child a laxative and place on the potty in 30 minutes.
- ) Make up a game to encourage the child to want to use the potty.
4.) Make up a game to encourage the child to want to use the potty.
The child is at Freud’s anal stage of development (1½ to 3 years). The major conflict of this stage is toilet training. The child needs to be able to maintain a sense of control, and training should be a pleasurable experience. That can be accomplished by making toilet training a game. Punishment and forcing a child to sit on the potty do not support the child’s sense of control. Laxatives are not appropriate unless recommended by the physician for constipation.
An 82-year-old client complains that he is “sick, old, and useless,” and that people are “no good and don’t care.” The nurse recognizes that these statements at this age indicate negative resolution of which task, according to Erikson?
- Integrity versus despair
- Identity versus role confusion
- Generativity versus stagnation
- Intimacy versus isolation
1. Integrity versus despair
The central task of maturity (65 years to death), according to Erikson, is integrity versus despair. Unsuccessful resolution results in a sense of loss and contempt for others. Identity versus role confusion is a task of adolescence. Generativity versus stagnation is a task of adulthood, and intimacy versus isolation is a task of young adulthood.
The nurse is developing a teaching plan for a 9-year-old female client who is diabetic. Which actions would be appropriate, according to Piaget?
- Teaching size of food portions and importance of timing snacks and meals
- Discussing future hazards of pregnancy for diabetic mothers
- Using hand puppets to teach proper nutrition
- Using hypothetical problem situations to teach potential problem solving
1. Teaching size of food portions and importance of timing snacks and meals
This child is at the concrete operations phase (ages 7-11), characterized by the ability to understand size relationships, solve concrete problems, understand left and right, and recognize viewpoints. Developmentally, the child should be able to understand portion size and timing of meals and snacks. The child is still focused on the here and now, so discussing future pregnancy hazards is not appropriate. Use of hypothetical problem situations is more appropriate to the formal operations phase (ages 11-18 years), and use of hand puppets is more appropriate for younger children.
A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started 1 month after the death of the client’s spouse. Which nursing diagnosis is most appropriate for this client?
- ) Activity intolerance
- ) Dysfunctional grieving
- ) Ineffective role performance
- ) Impaired physical mobility
2.) Dysfunctional grieving
Behavioral manifestations of Dysfunctional grieving include changes in eating habits, sleep patterns, and activity levels. Diagnoses of Activity intolerance, Ineffective role performance, and Impaired physical mobility don’t include these defining characteristics.
A client says to the nurse “I know that I’m going to die.” Which of the following responses by the nurse would be best?
- ) “We have special equipment to monitor you and your problem.”
- ) “Don’t worry. We know what we’re doing and you aren’t going to die.”
- ) “Why do you think you’re going to die?”
- ) “Oh no, you’re doing quite well considering your condition.”
3.) “Why do you think you’re going to die?”
A therapeutic approach would be to reflect on the client’s comments, focusing on his specific words. Telling the client that special equipment is available, that you know what to do and not to worry, and that he’s doing quite well are nontherapeutic responses. Such statements offer false reassurance and ignore the client’s needs.
A client is admitted completely immobilized by an acute exacerbation of multiple sclerosis. Two days later, the client cries frequently and refuses to see family members. The nurse formulates a nursing diagnosis of Hopelessness. To address this diagnosis, the nurse should include which intervention in the plan of care?
- Obtaining a sedation order
- Limiting visitors to 15-minute intervals, 4 times a day
- Encouraging the client to verbalize his feelings
- Reinforcing the client’s responsibility to the family
3. Encouraging the client to verbalize his feelings
Encouraging verbalization of feelings is an example of therapeutic communication, which the nurse uses to help the client express and work through feelings and problems related to his condition. Administering drugs, limiting visits, or reminding the client of responsibilities wouldn’t help the client work through feelings.
The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he’ll be undesirable to his wife and becomes tearful. He expresses that he’s been spoiled by a happy, satisfying sex life with his wife and says he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes?
- Situational low self-esteem
- Unilateral neglect
- Social isolation
- Risk for loneliness
- Situational low self-esteem
The signs and symptoms stated in this case may all be found in a client with low self-esteem. The diagnosis of Unilateral neglect occurs in neurologic illness or trauma when the client shows a lack of awareness of a body part. This client is at risk for social isolation and loneliness, but there is no indication in the case study that these diagnoses are present.
Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of her child?
- Unplanned
- Situational
- Maturational
- Physiologic
2. Situational
Adjustment to the birth of a child is an example of a situational change, which arises from the interaction between individuals and the environment. Because pregnancy is a 9-month process, the change isn’t unplanned. Adjustment to maturational change refers to that associated with puberty. Physiologic change refers to the events associated with aging and menopause.
The nurse receives a change-of-shift report for a 76-year-old client who had a total hip replacement. The client is not oriented to time, place, or person and is attempting to get out of bed and pull out an I.V. line that’s supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which actions by the nurse would be appropriate? (select all that apply)
- Assess and document the behavior that requires continued use of restraints.
- Tie the restraints in quick-release knots.
- Tie the restraints to the side rails of the bed.
- Ask the client if he needs to go to the bathroom and provide range-of-motion exercises every 2 hours.
- Position the vest restraints so that the straps are crossed in the back.
1. Assess and document the behavior that requires continued use of restraints.
2. Tie the restraints in quick-release knots.
4. Ask the client if he needs to go to the bathroom and provide range-of-motion exercises every 2 hours.
The client must be frequently reassessed to determine whether he is ready to have the restraints removed. The information should also be documented. Restraints should be tied in knots that can be released quickly and easily. Toileting and range-of-motion exercises should be performed every 2 hours while a client is in restraints. Restraints should never be secured to side rails because doing so can cause injury if the side rail is lowered without untying the restraint. A vest restraint should be positioned so the straps cross in front of the client, not in the back.
