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 reviewing the Healthy People 2020 leading health indicators for a child health promotion program. Which are included in the leading health indicators? (Select all that apply.)

Correct answer: C

Rationale: Healthy People 2020 focuses on decreasing tobacco use, improving immunization rates, and increasing access to healthcare among its leading health indicators.

3. What is the most effective method to prevent infection in the newborn?

Correct answer: B

Rationale: The most effective method to prevent infection in newborns is by practicing proper hand hygiene by staff and family. This is crucial as it helps reduce the transmission of infectious agents, protecting vulnerable newborns. Using disposable items may help, but proper hand hygiene is more effective. Administering prophylactic antibiotics without a specific indication can lead to antibiotic resistance and is not recommended. Isolating the newborn from others is not practical and may not be necessary if proper hand hygiene is maintained.

4. Which family theory is described as a series of tasks for the family throughout its life span?

Correct answer: B

Rationale: Developmental theory outlines the series of tasks and stages that a family goes through over its life span, helping to understand the family's development and needs over time.

5. At what age is binocularity, the ability to fixate on one visual field with both eyes simultaneously, typically achieved?

Correct answer: B

Rationale: Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is typically achieved by the age of 3 to 4 months. Achieving binocularity at 1 month is too early for most infants as their visual system is still developing. Similarly, 6 to 8 months and 12 months are beyond the normal age range for achieving binocularity, and delayed achievement could indicate potential issues like strabismus, which may lead to visual impairment if not addressed.

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