Nokea
After completing the mental status assessment of a 9-year-old boy, the nurse documents the findings. Which of the following would the nurse document as reflecting the child?s motor activity? Select all that apply.
- A. Favorite story, Huckleberry Finn
- B. Short attention span
- C. Hyperalertness
- D. Went to the park last weekend
- E. Nail biting
- F. History of temper tantrums
Correct Answer: B,C,E,F
Rationale: Motor activity includes short attention span (B), hyperalertness (C), nail biting (E), and temper tantrums (F), as they reflect observable behaviors. Favorite story (A) and park visits (D) are not motor-related.
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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.
A nurse in an outpatient clinic is assessing a child, and the nurse will interview the child and the child?s parents separately. Which of the following comments would the nurse anticipate the child making during the upcoming interview?
- A. I can?t get along with my parents.
- B. I yell at my parents a lot.
- C. I?m sad a lot, and I have trouble sleeping.
- D. I refuse to do what my parents tell me to.
Correct Answer: C
Rationale: Sadness and sleep issues (C) are common psychological symptoms in children that may be expressed in a clinical setting, especially given school behavior concerns. Parent conflict (A, B, D) may be reported, but sadness and sleep issues are more directly tied to internal distress.
A nurse is preparing an inservice presentation for a group of staff psychiatric nurses who will be providing care to children and adolescents in a new outpatient psychiatric clinic. When describing important issues related to interviewing children, which of the following would the nurse emphasize? Select all that apply.
- A. Use of simple terms such as sad or nervous instead of depressed or anxious.
- B. Need for individualization of questions based on judgment and discretion.
- C. Use of questions that lead the child to the desired response.
- D. Speaking in longer sentences that include a description of what is being asked.
- E. Need for the child?s statements and behaviors to guide the interview.
Correct Answer: A,B,E
Rationale: Using simple terms (A), individualizing questions (B), and following the child?s lead (E) are key to effective pediatric interviews. Leading questions (C) bias responses, and long sentences (D) may overwhelm young children.
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.
The nurse is beginning an assessment interview with an 8-year-old girl who has been brought in for counseling by her parents. When beginning the interview, which question would be most appropriate for the nurse to ask first?
- A. How are you feeling?
- B. How old are you?
- C. Has anyone told you about why you are here today?
- D. Why do you think I?m talking to you alone without your parents here?
Correct Answer: C
Rationale: Asking if the child knows why she is there (C) is a gentle, open-ended start that clarifies her understanding and builds rapport. Asking about feelings (A) may be too direct initially, age (B) is factual but less engaging, and questioning the absence of parents (D) may raise anxiety.