Author Question: During a well-baby health maintenance visit, the nurse notices the infant does not demonstrate ... (Read 34 times)

jayhills49 · **on:** Jun 25, 2018

During a well-baby health maintenance visit, the nurse notices the infant does not demonstrate expected developmental milestones for age. Which nursing intervention is the priority in this situation?

1. The nurse should initiate a consult with social services for a home assessment.
2. The nurse should consult with the health care provider.
3. The nurse should ask the parents questions about their play activities with the infant.
4. The nurse should prepare the family for a potentially upsetting diagnosis.

Question 2

An older adult client voices concerns to the nurse regarding the seemingly continued loss of family and friends to illness and death.

The client states, God is cruel. I have no one anymore. I am too old to make new friends; it's useless, everyone leaves me. Using Erickson's psychosocial theory, which interpretation by the nurse is the most appropriate based on the client's statements?
1. A successful mastering of the stage of integrity versus despair.
2. Difficulty passing through the stage of generativity versus stagnation.
3. A struggle to succeed in the stage of integrity versus despair.
4. Unsuccessful completion of the intimacy versus isolation stage of development.

annierak · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3
The nurse should first assess the parental knowledge and expectations concerning normal infant development. The parents may not be aware of the appropriate activities that will stimulate the child. It is outside the nurse's scope of practice to initiate consults. The healthcare provider will recommend and manage consultations. The nurse should complete the assessment before consulting with the health care provider. There is no need to prepare the parents for a negative outcome at this point.

Answer to Question 2

Correct Answer: 3

The client is experiencing struggles to succeed in the stage of integrity versus despair. During this phase (ages 65 to death), the client reflects on life and the inevitability of death. Clients are often faced with the loss of friends and family members. Acceptance of these losses results in successful movement through this stage. Failure to accept this stage of life will result in bitterness. During the stage of generativity versus stagnation (ages 40-65), the client either demonstrates productivity and creativity or begins to become self-absorbed and nonproductive. In the phase of intimacy versus isolation (ages 19-40) adults find mates or face a life of loneliness.