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During the initial physical examination, the nurse is most likely to detect which finding related to anorexia?
- A. Growth of fine body hair
- B. Bruises over the upper torso
- C. Hyperactive bowel sounds
- D. Club-shaped fingertips
Correct Answer: A
Rationale: Lanugo (fine body hair) develops in anorexia due to malnutrition.
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When providing care for the 3-year-old autistic child, which behavior is the nurse most likely to note?
- A. Constant use of the words 'I' and 'me'
- B. Insensitivity to pain
- C. Flexibility in normal routine
- D. Increased interest in others' actions
Correct Answer: B
Rationale: Insensitivity to pain is common in autism.
The nurse correctly explains that this is normal behavior for toddlers who are developing which psychosocial characteristic?
- A. Integrity
- B. Identity
- C. Autonomy
- D. Generativity
Correct Answer: C
Rationale: The 'no' phase reflects toddlers asserting autonomy, per Erikson's stages.
Which of the following nursing interventions is most appropriate to include when preparing a care plan for the child in the educational setting?
- A. Work with the teacher to establish clear behavioral expectations for the classroom.
- B. Place a chair in the corner of the room as a potential consequence for poor behavior.
- C. Allow the child to move about the room as desired provided the behavior is not disruptive.
- D. Plan separate learning experiences with more creative assignments and activities.
Correct Answer: A
Rationale: Clear expectations provide structure, beneficial for ADHD management.
If the teenage mother expresses feeling inexperienced and inadequate in caring for the baby, which referral is best?
- A. Project Head Start
- B. Planned Parenthood
- C. Parent-Teacher Association
- D. Parenting classes
Correct Answer: D
Rationale: Parenting classes provide education and support to build confidence and skills.
The nurse recognizes that methylphenidate hydrochloride (Ritalin) is classified as which type of drug?
- A. Central nervous system depressant
- B. Central nervous system stimulant
- C. Antidepressant
- D. Tranquilizer
Correct Answer: B
Rationale: Methylphenidate is a CNS stimulant used for ADHD.