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During the nursing assessment, which of the following suggests that the mother may be continuing to abuse heroin?
- A. The mother states, 'I am tired all the time and find myself needing to sleep when the baby sleeps.'
- B. The nurse notes a variety of small ecchymotic areas on the arms and legs of the mother.
- C. The mother appears indifferent to the crying of the newborn.
- D. The mother has a body odor and the newborn appears unkempt.
- E. The mother expresses an inability to afford public transportation to the clinic.
- F. The mother states that the father of the child is no longer associated with the family.
Correct Answer: B,C,D
Rationale: Ecchymotic areas suggest injection sites, indifference may indicate substance use, and poor hygiene is a common sign of ongoing abuse.
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Which area of the adolescent's social history is most appropriate for the clinic nurse to assess?
- A. Peer relationships
- B. School performance
- C. Church attendance
- D. Employment records
Correct Answer: A
Rationale: Peer relationships strongly influence gang involvement and antisocial behavior.
Which suggestion by the nurse would be most beneficial for the child's nutrition at this time?
- A. Continue to feed the child until the child tries to pick up food.
- B. Try giving the child finger foods while in the act of dressing.
- C. Leave the food until the child becomes hungry enough to eat it.
- D. Demonstrate how to use a spoon at every meal.
Correct Answer: C
Rationale: Hunger may motivate self-feeding in a structured environment.
After conferring with the nurse, which response by the receptionist to the mother is most appropriate at this time?
- A. The clinic cannot release that information.
- B. Your daughter will return the phone call shortly.
- C. You may talk to your daughter after her examination.
- D. Your daughter came to the clinic for birth control.
Correct Answer: A
Rationale: Confidentiality protects the teen's privacy, especially for reproductive health.
When crisis intervention is provided, which nursing action takes priority?
- A. Explaining the benefits of professional counseling
- B. Encouraging the survivors to talk about the event
- C. Reassuring the survivors that they will adapt
- D. Advising consulting a physician for drug therapy
Correct Answer: B
Rationale: Talking about the event helps process trauma and is a priority in crisis intervention.
If this child is typical of others the same age with a serious illness, which concept is the most commonly held belief about being ill?
- A. Illness is not life-threatening; recovery is assured.
- B. Significant others can prevent serious consequences.
- C. Illness is a punishment for some wrong-doing.
- D. Failure to comply with treatment results in parental rejection.
Correct Answer: C
Rationale: School-age children often view illness as punishment due to magical thinking.