the mother of a 6 year old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb
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Nursing Elites

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Nursing Care of Children ATI

1. The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?

Correct answer: B

Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.

2. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

Correct answer: C

Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.

3. What is the best age to introduce solid food into an infant’s diet?

Correct answer: B

Rationale: The introduction of solid foods is recommended at 4 to 6 months when the infant's digestive system is more developed and ready for solids.

4. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?

Correct answer: D

Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.

5. A parent and 4-year-old child are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the child doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?

Correct answer: C

Rationale: The correct answer is C. According to Erikson, the primary task of a preschool-aged child is to explore and assert control over their environment. This behavior is demonstrated by the child opening drawers, pulling out supplies, and examining them, showcasing curiosity and exploration. Choices A, B, and D do not align with the primary developmental task of a preschool-age child according to Erikson. Reading a book and singing a song are more passive activities, while roughhousing with the parent does not directly relate to exploration and asserting control over the environment.

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