Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing the growth and development of a 16-year-old adolescent. Which of the following behaviors or physical changes would the nurse expect to observe in a typical adolescent at this stage? (Select all that apply)
A. Full adult height and the cessation of body changes
Full adult height and the cessation of body changes is incorrect because while many adolescents are nearing adult height by age 16, some continue to grow, particularly males. Body changes may still be ongoing, so complete cessation of growth is not typical.
B. A decrease in growth rate and an increase in body fat distribution
A decrease in growth rate and an increase in body fat distribution is correct because by mid-adolescence, the rapid growth of puberty slows, and changes in body composition occur. Females typically experience an increase in body fat, while males may see a decrease in fat with increased muscle mass.
C. Heightened interest in forming intimate relationships outside the family
Heightened interest in forming intimate relationships outside the family is correct because adolescents at this stage begin exploring romantic and sexual relationships and may form emotional attachments with peers or romantic partners.
D. Increased independence and desire for privacy, with a focus on peer relationships
Increased independence and desire for privacy, with a focus on peer relationships is correct because autonomy and identity formation are key developmental tasks of adolescence. Adolescents seek privacy, rely more on peers, and may challenge parental authority as part of normal psychosocial development.
E. Development of secondary sexual characteristics such as facial hair in males and breast development in females
Development of secondary sexual characteristics such as facial hair in males and breast development in females is correct because most adolescents have completed or are in the later stages of puberty by age 16, with secondary sexual characteristics well established.
This question is an excerpt from Nurse Dive's nursing test bank - Ati dmmsn 650 OB/Pediatrics Proctored Exams. Take the full exam now
Full Explanation
A. Full adult height and the cessation of body changes is incorrect because while many adolescents are nearing adult height by age 16, some continue to grow, particularly males. Body changes may still be ongoing, so complete cessation of growth is not typical.
B. A decrease in growth rate and an increase in body fat distribution is correct because by mid-adolescence, the rapid growth of puberty slows, and changes in body composition occur. Females typically experience an increase in body fat, while males may see a decrease in fat with increased muscle mass.
C. Heightened interest in forming intimate relationships outside the family is correct because adolescents at this stage begin exploring romantic and sexual relationships and may form emotional attachments with peers or romantic partners.
D. Increased independence and desire for privacy, with a focus on peer relationships is correct because autonomy and identity formation are key developmental tasks of adolescence. Adolescents seek privacy, rely more on peers, and may challenge parental authority as part of normal psychosocial development.
E. Development of secondary sexual characteristics such as facial hair in males and breast development in females is correct because most adolescents have completed or are in the later stages of puberty by age 16, with secondary sexual characteristics well established.
Similar Questions
A 6-month-old infant is diagnosed with a congenital heart defect that causes a left-to-right shunt, resulting in increased pulmonary blood flow. Which of the following defects is most likely?
A. Coarctation of the Aorta
Coarctation of the Aorta is incorrect because this defect causes obstruction of blood flow from the left ventricle to the aorta. It is a pressure load problem (left ventricular hypertension) rather than a left-to-right shunt, and it does not primarily increase pulmonary blood flow.
B. Tetralogy of Fallot
Tetralogy of Fallot is incorrect because this is a cyanotic defect characterized by right-to-left shunting due to pulmonary stenosis and a VSD. Pulmonary blood flow is often decreased rather than increased.
C. Transposition of the Great Arteries
Transposition of the Great Arteries is incorrect because this is a cyanotic defect in which the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, resulting in parallel circulation. Pulmonary blood flow is not increased by a left-to-right shunt.
D. Ventricular Septal Defect (VSD)
Ventricular Septal Defect (VSD) is correct because it is a acyanotic defect that allows blood to flow from the left ventricle (higher pressure) to the right ventricle (lower pressure). This left-to-right shunt increases pulmonary blood flow, which can lead to symptoms such as tachypnea, poor weight gain, and frequent respiratory infections. VSDs are the most common congenital heart defect in infants.
Full Explanation
A. Coarctation of the Aorta is incorrect because this defect causes obstruction of blood flow from the left ventricle to the aorta. It is a pressure load problem (left ventricular hypertension) rather than a left-to-right shunt, and it does not primarily increase pulmonary blood flow.
B. Tetralogy of Fallot is incorrect because this is a cyanotic defect characterized by right-to-left shunting due to pulmonary stenosis and a VSD. Pulmonary blood flow is often decreased rather than increased.
C. Transposition of the Great Arteries is incorrect because this is a cyanotic defect in which the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, resulting in parallel circulation. Pulmonary blood flow is not increased by a left-to-right shunt.
D. Ventricular Septal Defect (VSD) is correct because it is a acyanotic defect that allows blood to flow from the left ventricle (higher pressure) to the right ventricle (lower pressure). This left-to-right shunt increases pulmonary blood flow, which can lead to symptoms such as tachypnea, poor weight gain, and frequent respiratory infections. VSDs are the most common congenital heart defect in infants.
A 7-year-old child is newly diagnosed with acute lymphoblastic leukemia (ALL). The nurse is preparing the family for the treatment plan. Which of the following nursing interventions is most important for the nurse to include in the plan of care for this child during the induction phase of chemotherapy?
A. Administering pain medications to relieve headache and muscle aches
Administering pain medications to relieve headache and muscle aches is important for comfort, but it is not the highest priority during the induction phase.
B. Monitoring for signs of infection due to neutropenia
Monitoring for signs of infection due to neutropenia is correct because induction chemotherapy causes profound bone marrow suppression, leading to neutropenia. Neutropenia significantly increases the risk of infection, which can become life-threatening. Early detection of fever, chills, or other infection signs is critical for timely intervention, making infection prevention and monitoring the top priority during this phase.
C. Recommending home-schooling to minimize exposure to other children
Recommending home-schooling to minimize exposure to other children is supportive and helpful for infection prevention but is secondary to direct monitoring and management of neutropenia.
D. Encouraging a high-protein diet to promote growth
Encouraging a high-protein diet to promote growth is beneficial for overall health and recovery but is not the primary concern during the induction phase, when preventing infection is life-saving.
Full Explanation
A. Administering pain medications to relieve headache and muscle aches is important for comfort, but it is not the highest priority during the induction phase.
B. Monitoring for signs of infection due to neutropenia is correct because induction chemotherapy causes profound bone marrow suppression, leading to neutropenia. Neutropenia significantly increases the risk of infection, which can become life-threatening. Early detection of fever, chills, or other infection signs is critical for timely intervention, making infection prevention and monitoring the top priority during this phase.
C. Recommending home-schooling to minimize exposure to other children is supportive and helpful for infection prevention but is secondary to direct monitoring and management of neutropenia.
D. Encouraging a high-protein diet to promote growth is beneficial for overall health and recovery but is not the primary concern during the induction phase, when preventing infection is life-saving.
Which of the following characteristics of the pediatric respiratory system makes infants and young children more susceptible to respiratory distress compared to adults?
A. Smaller airway diameter and immature respiratory muscles
Smaller airway diameter and immature respiratory muscles is correct because infants and young children have narrower airways, making them more prone to obstruction from edema, mucus, or inflammation. Additionally, their respiratory muscles, including the intercostals, are underdeveloped, so they rely heavily on diaphragmatic breathing. These factors increase the risk of respiratory distress during illness or airway compromise.
B. More developed diaphragm and increased lung compliance
More developed diaphragm and increased lung compliance is incorrect because infants have a less developed diaphragm and less compliant chest wall, not more. This makes breathing less efficient and increases susceptibility to fatigue and distress.
C. Larger airway diameter and more developed lung volume
Larger airway diameter and more developed lung volume is incorrect because infants have smaller airway diameter and smaller lung volumes compared to adults, which contributes to rapid desaturation during respiratory compromise.
D. Larger alveolar surface area and stronger respiratory muscles
Larger alveolar surface area and stronger respiratory muscles is incorrect because infants have fewer alveoli and weaker respiratory muscles, which limits gas exchange and makes them more vulnerable to hypoxia.
Full Explanation
A. Smaller airway diameter and immature respiratory muscles is correct because infants and young children have narrower airways, making them more prone to obstruction from edema, mucus, or inflammation. Additionally, their respiratory muscles, including the intercostals, are underdeveloped, so they rely heavily on diaphragmatic breathing. These factors increase the risk of respiratory distress during illness or airway compromise.
B. More developed diaphragm and increased lung compliance is incorrect because infants have a less developed diaphragm and less compliant chest wall, not more. This makes breathing less efficient and increases susceptibility to fatigue and distress.
C. Larger airway diameter and more developed lung volume is incorrect because infants have smaller airway diameter and smaller lung volumes compared to adults, which contributes to rapid desaturation during respiratory compromise.
D. Larger alveolar surface area and stronger respiratory muscles is incorrect because infants have fewer alveoli and weaker respiratory muscles, which limits gas exchange and makes them more vulnerable to hypoxia.