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 C
Explanation
Choice A rationale
Encouraging play exercises in the evening can lead to overstimulation, which can make it harder for the toddler to fall asleep. Physical activity should generally be done earlier in the day to help with sleep later on.
Choice B rationale
Turning off the room light can create a dark environment conducive to sleep, but it doesn’t address the need for a calming routine, which is essential for young children’s sleep. Some children also feel safer with a nightlight.
Choice C rationale
Providing bedtime rituals can help signal to the toddler that it is time to wind down and sleep. Consistent rituals, such as reading a story or singing a lullaby, provide a sense of security and comfort.
Choice D rationale
Explaining the source of the toddler’s fears may be beyond the cognitive ability of a toddler and does not directly promote sleep. It’s better to provide comfort and reassurance through routine.
Correct Answer is C
Explanation
Choice A rationale
The Industry vs. Inferiority stage, according to Erikson, occurs from age 6 to puberty, where children focus on learning, developing skills, and striving for competence. A 20-month-old
child is not yet in this stage.
Choice B rationale
The Trust vs. Mistrust stage is the earliest stage in Erikson's theory, occurring from birth to about 18 months. While a 20-month-old child has recently transitioned out of this stage, it
is not the stage applicable to their current developmental phase.
Choice C rationale
The Autonomy vs. Shame and Doubt stage occurs from approximately 18 months to 3 years. At 20 months, children are striving for independence, making choices, and developing a
sense of self-control, which is characteristic of this stage.
Choice D rationale
The Initiative vs. Guilt stage occurs from ages 3 to 6 years, where children begin to assert power and control through directing play and other social interactions. A 20-month-old child
is not in this stage yet.