The nurse would assess respirations in a 9-month-old infant when the client is:
Playing in the playroom.
Crying.
Sleeping.
Laughing.
The Correct Answer is C
Choice A rationale
Playing might cause irregular breathing patterns due to excitement or activity, making it hard to get an accurate respiratory rate.
Choice B rationale
Crying can alter the normal breathing rate and pattern, resulting in an inaccurate assessment of respirations.
Choice C rationale
Sleeping provides the most accurate assessment of respirations, as the infant’s breathing will be at its natural, resting rate.
Choice D rationale
Laughing, similar to crying, causes irregular breathing patterns due to physical exertion and emotions, affecting accuracy.
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Correct Answer is A
Explanation
Choice A rationale
Negative behaviors characterized by the need for autonomy are typical of toddlers. According to Erikson, this stage is known as autonomy versus shame and doubt, where toddlers
assert their independence and develop self-control.
Choice B rationale
Erikson's stage of initiative versus guilt applies to preschool children, not toddlers. This stage involves children beginning to assert power and control over their environment through
directing play and other social interactions.
Choice C rationale
The need to start a task and complete it is associated with Erikson's stage of industry versus inferiority, which applies to school-aged children, not toddlers. This stage involves
developing a sense of pride in their accomplishments.
Choice D rationale
The discovery of their identity is a characteristic of Erikson's stage of identity versus role confusion, which pertains to adolescence. During this stage, teenagers work on refining a
sense of self.
Correct Answer is A
Explanation
Choice A rationale
This choice offers the toddler control and options within boundaries. By allowing the child to choose between two cups, it reduces the power struggle inherent in negativism, where the child often says "no" to assert independence.
Choice B rationale
This choice presents a direct option of now or later, which may still lead to refusal due to the toddler's negativism. Toddlers often respond better to choices that are less direct.
Choice C rationale
Asking if the child can take the medicine is likely to result in a "no" due to the nature of negativism at this developmental stage. It does not give the toddler a sense of control or choice.
Choice D rationale
Asking the child to be "good" places a moral judgment on taking the medicine, which is not developmentally appropriate and may lead to resistance.