Nokea
After receiving the news about her pregnancy, which of the following occurrences is most beneficial to the pregnant adolescent at this time?
- A. A positive mothering instinct
- B. Making plans for marriage
- C. Financial support from her boyfriend
- D. Emotional support from her family
Correct Answer: D
Rationale: Family emotional support is critical for the teen's well-being during pregnancy.
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Of the following suggestions, which one would best prevent nursing personnel from becoming injured when providing the adolescent with care?
- A. Apply soft wrist restraints before ambulating the client.
- B. Ask a parent to care for the client.
- C. Explain steps involved in care before touching the client.
- D. Medicate the client immediately before ambulation.
Correct Answer: C
Rationale: Explaining steps reduces fear and potential for aggressive reactions.
Besides involuntary tremors, which other side effect should the nurse advise the family to anticipate?
- A. Muscle weakness
- B. Muscle atrophy
- C. Muscle contractures
- D. None of the above
Correct Answer: A
Rationale: Haloperidol can cause extrapyramidal symptoms, including muscle weakness.
When the nurse documents this incident, which wording is most appropriate?
- A. Became angry for no reason and an assault occurred.
- B. Hit caregiver unexpectedly even though not provoked.
- C. Struck nursing assistant when being helped from bed.
- D. Attacked nursing assistant without prior warning.
Correct Answer: C
Rationale: Objective language like 'struck' accurately describes the incident without bias.
If the 3-year-old child is typical of other autistic children, how would the nurse expect that child to respond to its parents?
- A. Indifference
- B. Playfulness
- C. Impatience
- D. None of the above
Correct Answer: A
Rationale: Autistic children often show indifference to social interactions.
Which strategy is most appropriate for developing a positive, therapeutic relationship with the injured child at the time of assessment?
- A. The nurse should make an effort to have prolonged eye contact with the child.
- B. The nurse should maintain a body position at the same level as the child.
- C. The nurse should separate the child from the parent during the interview.
- D. The nurse should ask the child direct questions about the parent.
Correct Answer: B
Rationale: A non-threatening posture at the child's level builds trust.