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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 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 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 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 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.
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.