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An adolescent girl is brought to the hospital emergency department by her parents after being raped. The girl is calm and controlled throughout the interview and examination. The nurse should recognize this behavior is what?
- A. A sign that a rape has not actually occurred
- B. One of a variety of behaviors normally seen in rape victims
- C. Indicative of a higher than usual level of maturity in the adolescent
- D. Suggestive that the adolescent had severe emotional problems before the rape occurred
Correct Answer: B
Rationale: Rape victims exhibit varied responses, including calm behavior, which may mask inner turmoil. This is a normal coping mechanism, not indicative of the event?s validity, maturity, or pre-existing emotional issues.
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The nurse should know what about Lyme disease?
- A. Very difficult to prevent
- B. Easily treated with oral antibiotics in stages 1, 2, and 3
- C. Caused by a spirochete that enters the skin through a tick bite
- D. Common in geographic areas where the soil contains the mycotic spores that cause the disease
Correct Answer: C
Rationale: Lyme disease is caused by Borrelia burgdorferi, a spirochete transmitted through a tick bite, leading to symptoms like erythema migrans. Prevention involves avoiding tick-infested areas and wearing protective clothing. It is not caused by mycotic spores, and while treatable with antibiotics, later stages may require more complex treatment.
Parents phone the nurse and say that their child just knocked out a permanent tooth. What should the nurses instructions to the parents include?
- A. Place the tooth in a dry container for transport.
- B. Hold the tooth by the crown and not by the root area.
- C. Transport the child and tooth to a dentist within 18 hours.
- D. Take the child to hospital emergency department if his or her mouth is bleeding.
Correct Answer: B
Rationale: Holding the tooth by the crown prevents damage to the root, which is critical for reimplantation. The tooth should be kept moist in milk or saline, seen by a dentist immediately, and bleeding is expected but not the primary reason for emergency care.
The middle school nurse is planning a behavior modification program for overweight children. What is the most important goal for participants of the program?
- A. Learn how to cook low-fat meals.
- B. Improve relationships with peers.
- C. Identify and eliminate inappropriate eating habits.
- D. Achieve normal weight during the program.
Correct Answer: C
Rationale: Identifying and eliminating inappropriate eating habits is the core of behavior modification, addressing root causes of obesity. Cooking skills are secondary, peer relationships are not the focus, and normal weight is a long-term goal.
During the physical examination of an adolescent with significant weight loss, what finding may indicate an eating disorder?
- A. Diarrhea
- B. Amenorrhea
- C. Appetite suppression
- D. Erosion of tooth enamel
Correct Answer: D
Rationale: Erosion of tooth enamel is a sign of bulimia nervosa due to repeated vomiting. Amenorrhea may occur in anorexia nervosa but is less specific, diarrhea relates to other conditions, and appetite suppression is not a physical exam finding.
What behavior is the nurse most likely to assess in an adolescent with anorexia nervosa (AN)?
- A. Eats in secrecy
- B. Uses food as a coping mechanism
- C. Has a marked preoccupation with food
- D. Lacks awareness of how eating affects weight loss
Correct Answer: C
Rationale: Individuals with AN are preoccupied with food, often preparing it for others or hoarding it while eating minimally. Secret eating and using food as a coping mechanism are typical of bulimia nervosa, and those with AN are aware of calorie intake?s impact.