Nokea
A home-health nurse is working with a poverty-stricken family that has two small children, ages 2 and 3 years. The family lives in an isolated rural area. The family?s home has a dirt floor, and there are chickens living in the house with the family. Because of a recent wind storm, there is a sizeable hole in the roof that lets rain and snow into the house. Which nursing intervention would be the highest priority in this situation?
- A. Make immunization appointments for the children in a nearby town?s public health clinic.
- B. Help the family find funding and manpower to patch and repair the roof of their home.
- C. Determine the educational readiness of the two children.
- D. Report the family for child abuse because of neglect.
Correct Answer: B
Rationale: Repairing the roof is the highest priority to ensure a safe, habitable environment, protecting the children from health risks due to exposure. Immunizations are important but less urgent, educational readiness is secondary, and reporting neglect is premature without assessing intent or resources.
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The nurse is planning an initial therapy session with a 20-year-old patient whose parents had alcoholism. The nurse anticipates that the patient would most likely exhibit symptoms of which of the following?
- A. Delusions
- B. Paranoid delusions
- C. Low self-concept
- D. Extroversion
Correct Answer: C
Rationale: Children of alcoholics often develop low self-concept due to unstable family dynamics, neglect, or emotional stress. Delusions or paranoid delusions are not typical without a psychotic disorder, and extroversion is a personality trait, not a symptom.
A group of nursing students is reviewing information about the differences that occur with grieving in children, adolescents, and adults. The students demonstrate understanding of this information when they identify which of the following as characteristic of adolescents?
- A. View death as reversible
- B. Mourn by talking about the loss
- C. Need repeated explanations to understand the loss
- D. Express a time limit for socially acceptable grieving
Correct Answer: B
Rationale: Adolescents typically mourn by talking about the loss, as they have developed cognitive and social skills to express grief verbally. Viewing death as reversible or needing repeated explanations is characteristic of younger children, and time limits for grieving are not typical.
While engaging in a discussion with a group of teens about risk behaviors, one of the teens says, 'That will never happen to me.' The nurse interprets this as which of the following?
- A. Invincibility fable
- B. Formal operations
- C. Egocentric thinking
- D. Relational aggression
Correct Answer: A
Rationale: The statement reflects the invincibility fable, a common adolescent belief that they are immune to negative consequences. Formal operations refer to cognitive development, egocentric thinking is self-focused but not specific to risk, and relational aggression involves social harm, not denial of risk.
A nurse is providing teaching to a group of parents with children and adolescents who have experienced losses. The nurse determines that the teaching was successful when the group states which of the following?
- A. Children grieve in similar ways regardless of their age.
- B. Children often use fantasy to fill in their gaps in understanding.
- C. Families tend to grieve at similar times after the loss.
- D. Children and adults grieve much in the same manner.
Correct Answer: B
Rationale: Children often use fantasy to process grief, filling gaps in their understanding due to developmental limitations, indicating successful teaching. Grief varies by age, families may grieve at different times, and children?s grief differs from adults? due to cognitive differences.
A nurse is developing a plan of care for a family who is experiencing problems related to their child?s chronic illness. The nurse plans to have the family read a group of short stories written by parents of children with chronic illnesses. The nurse will be using which technique?
- A. Psychoeducation
- B. Social skills training
- C. Bibliotherapy
- D. Assertiveness training
Correct Answer: C
Rationale: Using stories written by parents of chronically ill children is bibliotherapy, which promotes insight and coping through reading relevant materials. Psychoeducation involves direct teaching, social skills training targets interpersonal behaviors, and assertiveness training focuses on communication skills.