NR-222 Health and Wellness - Set 4 - Part 1

Correct Answer: Trust versus mistrust

An infant who has learned that signaling brings no response stops signaling, which is mistrust taking hold. Trust is built when a consistent caregiver reliably and promptly meets the infant's needs. Option a is incorrect because that conflict belongs to the toddler who can walk, refuse, and make choices. A four month old has no capacity yet to assert control over dressing, food, or toileting. Option b is incorrect because initiative belongs to the preschool years, when a child invents games, makes plans, and asks endless questions. Planning and starting projects are far beyond an infant of this age. Option d is incorrect because industry is the school age task of mastering skills and measuring oneself against classmates. Peers, schoolwork, and achievement play no part in the life of a four month old.

Correct Answer: Tell the parents regression is normal and temporary

Regression under the stress of illness is expected and short lived. Naming it for the parents keeps them from responding with shame, which is the exact outcome this stage is trying to avoid. Option b is incorrect because retraining during acute illness sets the child up to fail. Skills are restored after recovery, and pushing now adds a second battle to a child already coping with hospitalization. Option c is incorrect because comparing the child to some standard of maturity delivers the message that his body has betrayed him. Shame and doubt are precisely what the nurse should be preventing. Option d is incorrect because restricting fluids in a child with pneumonia risks dehydration and thickened secretions. It also treats a normal developmental response as a plumbing problem to be engineered away.

Correct Answer: Preconventional level, obedience and punishment orientation

Avoiding punishment is the whole justification, with no bargain, no relationship, and no principle in sight. That places the reasoning at the first stage of the preconventional level. Option a is incorrect because that stage runs on wanting specific people to approve. A child reasoning there would say he takes the medicine so his mother and nurse feel proud of him. Option b is incorrect because law and order reasoning widens the frame to society and duty. The justification would sound like following the prescriber's order because rules keep the whole system working. Option c is incorrect because social contract thinking treats laws as agreements that serve human welfare and can be changed democratically. Almost no children reason that way, and most adults never reach it either.

Correct Answer: Emergence of object permanence

Searching for an object that has disappeared shows the infant understands it still exists somewhere. Object permanence emerges at about eight to nine months and is functionally present by the first birthday. Option a is incorrect because conservation belongs to the concrete operational school age child, who grasps that pouring liquid into a taller glass does not change its amount. That is years away from this infant. Option b is incorrect because stranger fear shows itself as clinging, protesting, or crying when an unfamiliar adult approaches. The infant's reaction to a missing spoon says nothing about who is holding him. Option d is incorrect because pretend play, such as feeding a doll or talking into a toy phone, arrives with symbolic thought in the toddler years. A nine month old is still learning through senses and motion.

Correct Answer: A soft, flat, diamond shaped area

The anterior fontanelle stays open until twelve to eighteen months and should feel soft and flat in a quiet upright infant. Its diamond shape sits between the frontal and parietal bones. Option b is incorrect because a fontanelle that stays tense and raised in a calm upright infant points to increased intracranial pressure from meningitis, hydrocephalus, or abusive head trauma. That is an emergency. Option c is incorrect because a depression below the level of the skull signals dehydration. The nurse would look for poor skin turgor, few wet diapers, and dry mucous membranes to confirm it. Option d is incorrect because closure this early raises concern for craniosynostosis, which restricts brain growth. The posterior fontanelle is the one already closed by about two months in a six month old.

Correct Answer: A two month old whose mother smokes and bed shares

Risk peaks between one and four months, and maternal smoking plus bed sharing are two of the strongest modifiable risk factors. This combination puts the two month old at highest risk. Option a is incorrect because about ninety percent of these deaths happen before six months, and a crib is the recommended surface. A ten month old sleeping alone in a crib sits at the low end of risk. Option b is incorrect because exclusive breastfeeding is protective rather than harmful, and the protection grows the longer it continues. Nothing in this infant's description raises the risk above baseline. Option c is incorrect because room sharing without bed sharing is the arrangement recommended for at least the first six months. It substantially lowers risk, so this one month old is comparatively well protected.

Correct Answer: We will place her on her back for every sleep.

Back to sleep applies to every sleep and every caregiver until the first birthday. Supine placement is the single most protective action against sleep related infant death in the first year. Option a is incorrect because side lying is unstable and rolls easily into the prone position. It is not an accepted alternative, and reflux is not a reason to abandon supine placement. Option b is incorrect because bed sharing raises the risk of sleep related death. What the parents should hear instead is room sharing, with the infant on a separate firm surface beside the bed. Option d is incorrect because positioners and wedges are banned from the sleep space. They create entrapment and suffocation hazards, and spitting up is managed by feeding and burping rather than by propping.

Correct Answer: Give simple, concrete, sequential steps with a diagram

Cognition regresses under pain, fear, and sedation, so an educated adult may temporarily need concrete operational level teaching. Simple sequential steps with a visual aid meet him where he is right now. Option b is incorrect because abstract reasoning is the first capacity to fail when a person is terrified and in pain. Layering rationale onto an overwhelmed client adds noise rather than understanding. Option c is incorrect because he needs to understand what is happening to him right now, not later. Postponing everything leaves him without the orientation that would lower his fear during the workup. Option d is incorrect because outsourcing the explanation strips the client of participation in his own care. A relative may also be frightened, and the nurse still owns the responsibility for verifying understanding.

Correct Answer: Apply an adhesive bandage he chooses

Preschoolers have poorly defined body boundaries and fear that their insides will leak out through a break in the skin. A bandage visibly restores integrity, and choosing it restores some control. Option a is incorrect because showing the filled tube makes the loss concrete and larger in his mind. Seeing his blood outside his body is more likely to confirm the fear than to settle it. Option b is incorrect because circulation is an abstract idea and this child thinks in literal, concrete terms. A physiology explanation sails past him while the hole in his skin is still there. Option d is incorrect because distraction has its place during a procedure, not as a substitute for answering afterward. Steering him away leaves the worry intact and signals that the question is unwelcome.

Correct Answer: Development is cumulative, so stages build forward

Each stage rests on the resolution of the one before it, so an unmet need for basic trust leaves less foundation for adult intimacy. The disadvantage is real but not permanent. Option a is incorrect because head to toe progression describes the physical direction of motor control. It explains why an infant holds the head steady before sitting, and says nothing about relationships. Option b is incorrect because failure at a stage is a burden, not a sentence. Erikson held that earlier conflicts can be revisited and partly repaired through later relationships, including a therapeutic one with a nurse. Option c is incorrect because rate varies widely between individuals even though sequence does not. Two children reach the same milestone months apart and both remain normal, which has no bearing on this adult's history.

Correct Answer: Move the infant to the crib on his back

Car seats, swings, and bouncers are transport and awake time devices, not sleep surfaces. A sleeping infant is moved to a firm flat surface and placed supine as soon as it is practical. Option a is incorrect because leaving a sleeping infant in a sitting device allows the head to slump forward and narrow the airway. Convenience is not a reason to delay the move to a crib. Option c is incorrect because adjusting the seat only makes a hazardous sleep location slightly tidier. A reclined carrier still fails the firm and flat requirement, and no strap setting turns it into a bed. Option d is incorrect because rolled blankets act as positioners, and positioners have no place near a sleeping infant. Adding one introduces a suffocation hazard on top of the wrong sleep surface.

Correct Answer: Persistent head lag when pulled to sit

Head lag should resolve by four to six months, so lag that remains at seven months needs neurologic and developmental evaluation. It belongs in the same category as a retained primitive reflex. Option a is incorrect because stepping normally fades around four to eight weeks of age. Its absence at seven months is maturation working exactly as it should, and parents often need that reassurance. Option b is incorrect because a Babinski response with toe fanning stays normal in infancy while the corticospinal tract myelinates. It only becomes an abnormal sign in an older child or adult. Option c is incorrect because the plantar grasp is commonly taught to fade between eight and twelve months. Finding it at seven months is on time and does not warrant a referral.

Correct Answer: Organ structures form early, so folic acid must start before conception.

Organogenesis in the first trimester is a true critical window, and neural tube closure happens before many people know they are pregnant. That is why folic acid is started around conception. Option b is incorrect because susceptibility is not flat across gestation. The first trimester carries far higher risk for structural malformation, which is precisely what makes it a critical rather than an ordinary window. Option c is incorrect because that description belongs to a sensitive period, where the opportunity narrows but does not close. In a critical period the structure either forms on schedule or the chance is lost. Option d is incorrect because the most dramatic examples happen before birth, during weeks three through eight of gestation. Postnatal windows such as language and attachment exist too, but they are sensitive rather than critical.

Correct Answer: This quiet phase means his distress has deepened.

This is the despair phase of separation. Quiet withdrawal is routinely misread as settling in, but it signals deepening distress, and the answer is rooming in and consistent parental presence. Option a is incorrect because that reading is the exact trap this phase sets. Staff who record a child as adjusted stop pressing for parental presence at the moment the child most needs it. Option b is incorrect because pain relief would leave a toddler more interactive, not less. A comfortable child watches, reaches, plays, and greets his mother rather than turning his face toward the wall. Option d is incorrect because separation anxiety peaks during toddlerhood and does not fade over three days in an unfamiliar place. Skills are lost under this kind of stress, never gained.

Correct Answer: A normal tonic neck reflex

The fencing posture, with the face side arm and leg extended and the occiput side limbs flexed, is the asymmetric tonic neck reflex. It is expected until about three to four months. Option b is incorrect because the Moro reflex is triggered by sudden loss of support and produces symmetric arm abduction with an embrace. Head position alone does not elicit it. Option c is incorrect because brachial plexus injury shows up as an asymmetric Moro or a limp arm that does not move, not as a posture that changes with head turning. Option d is incorrect because cerebral palsy would be suspected if this posturing persisted well past the expected window and blocked midline hand play. At three months the finding is still on schedule.

Correct Answer: Suppression, setting the thought aside consciously

She knows the result and is deliberately postponing it, which makes the act conscious. Suppression is the chosen setting aside of a distressing thought, and it is the pair students most often confuse. Option a is incorrect because repression happens outside awareness, as when a trauma survivor has no recollection of the event at all. This client can state her result and her timeline precisely. Option b is incorrect because denial rejects the external reality outright. A client using it would insist the laboratory mixed up her specimen, not schedule a time to face the news. Option d is incorrect because projection moves an unacceptable feeling onto somebody else. The classic example is an angry client insisting that every nurse on the unit is furious with him.

Correct Answer: He has entered the despair phase of separation

Bowlby described protest giving way to despair, and the quiet child is often worse rather than better. Documenting that he adjusted well would hide a child who has given up signaling for his mother. Option a is incorrect because stillness in a separated toddler is not the same as comfort. Charting a good adjustment on the basis of silence is the documentation error this phase is famous for causing. Option c is incorrect because attachment patterns are judged at reunion, not during absence. A securely attached child protests separation and then settles quickly once the caregiver returns to the room. Option d is incorrect because two days in hospital cannot erase a normal developmental response. Separation anxiety peaks through the toddler years, so the sudden calm needs a different explanation than growth.

Correct Answer: Keep her safe without waking her

This is a sleep terror, arising from deep non rapid eye movement sleep in the first third of the night. The child is not truly awake, so the parents keep her from injury and wait it out. Option a is incorrect because waking is the nightmare response, and here it usually prolongs and worsens the episode. A child in this state cannot be consoled because she is not actually awake. Option b is incorrect because there is no dream to discuss. Sleep terrors leave no memory at all, unlike nightmares, which the child recalls vividly and often wants to talk through the next day. Option c is incorrect because a night light helps a child who is frightened of the dark while awake. It does nothing during an event that begins in deep sleep and never brings the child to consciousness.

Correct Answer: Both fall within normal variation in pace

The order of milestones is fixed but the timing belongs to the individual child. Walking anywhere across that span is ordinary variation, and neither infant has broken the expected sequence. Option a is incorrect because fifteen months still sits inside the accepted range for independent walking. Nurses judge delay against the upper limit of normal, not against the average, which prevents needless alarm. Option c is incorrect because nothing in the scenario says a step was skipped. Skipping would mean walking before sitting independently, and that broken order is the finding worth investigating rather than early competence. Option d is incorrect because referral consumes family time and money for no benefit here. Both infants met the milestone in sequence, and a specialist would only confirm what the nurse can already document.

Correct Answer: Falls from an elevated surface

Falls are the most common nonfatal infant injury. An infant left even briefly on a changing table, bed, sofa, or counter can roll or push off, so the caregiver keeps one hand in contact. Option a is incorrect because poisoning peaks in the toddler years, when the child can walk to a cabinet, open it, and swallow the contents. A four month old cannot yet reach those products. Option b is incorrect because drowning is a real and deadly infant risk, but it is far less frequent than falling. Bathtubs and buckets, not backyard pools, are where infants most often drown. Option c is incorrect because scald injury from a microwaved bottle is preventable and uncommon once parents are taught never to microwave. Frequency here does not come close to what happens on changing tables.