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A nurse is performing an assessment interview of a 14-year-old boy who is being admitted to an adolescent substance abuse unit. His parents are concerned about their son?s repeated problems at school that they associate with his drug use. The boy stalks into the office, abruptly sits down, crosses his arms, and says, Okay, ask your stupid questions, but don?t expect me to cooperate! Which response by the nurse would be most appropriate?
- A. Your attitude is offensive; I can see why your parents brought you here.
- B. Why don?t we wait until you?ve calmed down a bit to start the interview?
- C. Why are you so angry?
- D. You seem pretty upset. Tell me about what is upsetting you.
Correct Answer: D
Rationale: Acknowledging the adolescent?s upset feelings and inviting discussion (D) validates emotions and encourages engagement. Criticizing attitude (A) alienates, delaying the interview (B) dismisses the moment, and questioning anger (C) may feel confrontational.
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The nurse is preparing to interview a 6-year-old girl and her mother in an outpatient psychiatric setting. To establish a treatment alliance with the child, the nurse should:
- A. Tell the child she watches Sesame Street all the time.
- B. Talk to the child while standing up and looking down at her.
- C. Tell the child that this must be a bit scary for her.
- D. Ask the parent if the child can be interviewed alone.
Correct Answer: C
Rationale: Acknowledging the child?s potential fear (C) validates her emotions, fostering trust and a treatment alliance. Claiming to watch Sesame Street (A) may seem inauthentic, standing over the child (B) is intimidating, and interviewing alone (D) may be premature for a young child.
A child and the child?s family visit a psychiatric outpatient setting because the parent is concerned about the child?s behavior at school. The child scores 65 on the Global Assessment of Functioning (GAF) scale. The nurse interprets this finding as which of the following?
- A. The child requires inpatient therapy.
- B. The child is experiencing homicidal thoughts.
- C. The child is functioning well in the area of school.
- D. The child can be treated effectively as an outpatient.
Correct Answer: D
Rationale: A GAF score of 65 indicates mild symptoms with generally good functioning, suggesting outpatient treatment (D) is appropriate. Inpatient therapy (A) is for lower scores, homicidal thoughts (B) are not indicated by this score, and school functioning (C) is not specifically supported.
To establish rapport with a 10-year-old child who is hospitalized in a psychiatric setting, which statement by the nurse would be most appropriate?
- A. Let?s compare your situation to that of Cinderella?s in the fairy tale.
- B. I?m going to use the DECA tool to measure your self-control and initiative.
- C. Let?s have you draw a picture of yourself.
- D. Would you like to play a game of checkers with me?
Correct Answer: D
Rationale: Playing a game like checkers (D) is an engaging, non-threatening way to build rapport with a 10-year-old. Comparing to a fairy tale (A) may confuse, mentioning assessment tools (B) is too clinical, and drawing (C) may feel directive before trust is established.
A nurse is interviewing a 12-year-old boy who has been diagnosed with depression. The client?s depression was triggered by the death of his father 2 years ago. The nurse interprets which comment made by the boy as reflecting egocentrism?
- A. If I hadn?t yelled at my dad and told him to go away, he never would have died.
- B. I?m still sad because my dad died a couple of years ago.
- C. I think I?m just experiencing normal grieving.
- D. My father was the best friend I ever had; I still can?t believe he?s gone for good.
Correct Answer: A
Rationale: Blaming himself for his father?s death (A) reflects egocentrism, a developmental trait where the child believes their actions directly cause external events. Sadness (B), normal grieving (C), and loss acknowledgment (D) are typical grief responses, not egocentrism.
A nurse is preparing to assess a 9-year-old child who has been sexually abused. Which of the following would be the priority for the nurse?
- A. Finding out when the abuse occurred
- B. Documenting the assessment for use in court
- C. Using anatomically correct dolls to elicit information
- D. Ensuring that the environment is safe and supportive
Correct Answer: D
Rationale: Ensuring a safe and supportive environment (D) is the priority to reduce trauma and build trust during assessment. Timing (A), documentation (B), and dolls (C) are secondary to creating a secure setting for the child.