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's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?

Correct answer: A

Rationale: Preschoolers may engage in magical thinking and believe inanimate objects are alive, so the nurse should explain the equipment in a way that reduces fear.

3. What is the most consistent and commonly used indicator of pain in infants?

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

4. What diagnostic test allows visualization of renal parenchyma and renal pelvis without exposure to external-beam radiation or radioactive isotopes?

Correct answer: A

Rationale: Renal ultrasonography provides imaging of the renal parenchyma and pelvis without the risks associated with radiation or radioactive isotopes, making it a safer option, especially for children.

5. Which type of family should the nurse recognize when a mother, her children, and a stepfather live together?

Correct answer: B

Rationale: A blended family consists of a couple and their children from this and all previous relationships, including stepfamilies.

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