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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.
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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.
A group of nursing students is reviewing information about temperament and its effect on the child?s behavior. The students demonstrate understanding of the concept when they identify which of the following as characteristic of temperament. Select all that apply.
- A. Emotional bonding
- B. Sequential growth processes
- C. Activity level
- D. Adaptability
- E. Insecurity
Correct Answer: C,D
Rationale: Temperament includes activity level (C) and adaptability (D), innate traits influencing behavior. Emotional bonding (A) and growth processes (B) are developmental, and insecurity (E) is a state, not a temperament trait.
A nurse is preparing to complete a mental status examination of an adolescent who is experiencing behavioral problems at school. When assessing the adolescent?s thought processes, which of the following would the nurse need to keep in mind about this age group? Select all that apply.
- A. View of things in a concrete manner
- B. Ability to look at things hypothetically
- C. Beginning ability to use logic
- D. Ability to use abstract thinking
- E. Difficulty in putting feelings into words
Correct Answer: B,C,D,E
Rationale: Adolescents develop hypothetical thinking (B), logical reasoning (C), abstract thinking (D), and often struggle to verbalize feelings (E). Concrete thinking (A) is more typical of younger children.
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 nurse is interviewing a 12-year-old child in an outpatient psychiatric setting. Which of the following would be most appropriate for the nurse to say to establish a high degree of credibility?
- A. How would you describe your parents?
- B. Tell me about your best friend.
- C. I have several teddy bears; would you like one to hold?
- D. You?d get along better with your parents if you?d follow their advice.
Correct Answer: B
Rationale: Asking about the child?s best friend (B) is age-appropriate and non-threatening, building rapport and credibility. Asking about parents (A) may feel confrontational, offering a teddy bear (C) is too juvenile for a 12-year-old, and giving advice (D) is judgmental and undermines trust.