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Terms in this set (675)

1,2

The child who had a previous shunt revision and the adolescent who is 4 days post spinal fusion will be the most stable and will require the least skill level when compared with the other choices. On a general pediatric unit, the nurse would be familiar with checking for increased ICP, which would be necessary for caring for any client with a previous shunt revision. Immediately postop, the adolescent with spinal fusion would require special turning and lung assessment to prevent and observe for congestion/pneumonia, skills not acquired on a general floor. However, at 4 days postop this client should be ambulating and will not need specialized turning, so the nurse from the general pediatric unit could care for this client.
3. Incorrect: This client is more acute and requires a higher skill level. Nursing care for this child would involve frequent neurologic assessments and monitoring for infection. The child should also be monitored for signs of possible complications including bowel perforation.
4. Incorrect: This client is more acute and requires a higher skill level. The nurse on the general pediatric unit would not be experienced in caring for a child on a ventilator.
5. Incorrect: This client is more acute and requires a higher skill level. A child who is fresh post-op following a tracheostomy is at risk for airway obstruction from thick secretions, mucous plug, blood clot or dislodgement of the tube. Cardio-respiratory arrest can occur from these complications. The child is also at risk for hemorrhage. Nursing care would include frequent suctioning as needed, monitoring for early signs of airway obstruction, and trach care. The nurse from the general pediatric unit may not have the skills required to care for this child who also has cerebral palsy which could complicate the care required.
1

Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops.

2. Incorrect: Generativity versus Stagnation is the major task for 40-64 year olds. To achieve the life goals established for oneself while also considering the welfare of future generations. The primary developmental task during this middle age period is one in which the individual contributes to society as well as helping to guide future generations. A sense of generativity (sense of productivity and accomplishment) often results from such things as raising a family and helping to better the society. In contrast, those individuals not willing to work to better society and those who are egocentric and self-centered often develop a sense of stagnation (dissatisfaction and the lack of productivity)
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3. Incorrect: Intimacy versus Isolation is the objective from 20-39 year olds to form an intense, lasting relationship or a commitment to another person. If the individual cannot form the intimate relationships (possibly due to personal needs) a sense of isolation may develop which can lead to feelings of depression.

4. Incorrect: Industry versus Inferiority is the major task for 6-12 year olds in which they attempt to achieve a sense of self confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances. The child must develop the ability to deal with the demands of learning new social and academic skills, or a sense of inferiority, failure, or incompetence may result.
4

Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention. Extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; delusions and hallucinations.
1. Incorrect: Wernicke's Encephalopathy represents the most severe form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, confusion, somnolence, and stupor. If thiamine replacement therapy is not given, death will ensue.
2. Incorrect: Korsakoff's Psychosis is identified by a syndrome of confusion, personality changes, loss of recent memory, and confabulation (filling in some memory gaps with different life events or created thoughts). It is frequently encountered in clients recovering from Wernicke's encephalopathy. Coordination may be affected, so the client may have difficulty maintaining balance. Treatment is parenteral or oral thiamine replacement.
3. Incorrect: Alcohol withdrawal typically begins 4-12 hours after cessation of or reduction in heavy and prolonged alcohol use. Symptoms include: coarse tremor of hands, tongue, or eyelids; nausea and vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or delusions; headache; and insomnia