Nokea
Which assessment finding would lead the nurse to suspect physical abuse?
- A. The child protests when approached by the nurse.
- B. The child has patchy loss of hair.
- C. The child has a fresh bruise on the forehead.
- D. The child has an abrasion on the right knee.
Correct Answer: C
Rationale: A fresh bruise in an unusual location raises suspicion of abuse.
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Which statement is the best explanation for the adolescent's behavior?
- A. Aggression is a common behavior manifested by cognitively disabled people.
- B. Aggression is a response that occurs when a person feels frustrated or frightened.
- C. Aggression is an indication that the client has a poor opinion of the care provided.
- D. Aggression is a common way for adolescents to communicate they are experiencing pain.
Correct Answer: B
Rationale: Frustration or fear often triggers aggression in cognitively disabled individuals.
Which strategy is most appropriate for developing a positive, therapeutic relationship with the injured child at the time of assessment?
- A. The nurse should make an effort to have prolonged eye contact with the child.
- B. The nurse should maintain a body position at the same level as the child.
- C. The nurse should separate the child from the parent during the interview.
- D. The nurse should ask the child direct questions about the parent.
Correct Answer: B
Rationale: A non-threatening posture at the child's level builds trust.
Which assessment finding best indicates that a child taking methylphenidate hydrochloride (Ritalin) is experiencing undesirable side effects?
- A. The child has altered elimination patterns.
- B. The child develops intolerance to certain foods.
- C. The child has an elevated blood pressure.
- D. The child has evidence of skin breakdown.
Correct Answer: C
Rationale: Elevated blood pressure is a concerning side effect of Ritalin.
When discussing the home environment with the parents, the nurse should explain that which one of the following is the most appropriate environment for an autistic child?
- A. Stimulating, with a variety of sensory experiences
- B. Consistent, with a minimum of physical change
- C. Flexible, with the freedom to initiate activity
- D. Strict, with narrow limits for acceptable behavior
Correct Answer: B
Rationale: Consistency minimizes anxiety and supports routine.
Besides involuntary tremors, which other side effect should the nurse advise the family to anticipate?
- A. Muscle weakness
- B. Muscle atrophy
- C. Muscle contractures
- D. None of the above
Correct Answer: A
Rationale: Haloperidol can cause extrapyramidal symptoms, including muscle weakness.