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If ruminations about suicide are present, which observation by the nurse is most significant?
- A. The teen is not attending school regularly.
- B. The teen is hoarding sharp objects in the bedroom.
- C. The teen is not completing homework assignments.
- D. The teen is not participating in extracurricular activities.
Correct Answer: B
Rationale: Hoarding sharp objects indicates a high risk for self-harm.
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The nurse is aware that whenever preparing a school-age child for a procedure, test, or medical treatment, which is the most important information to convey?
- A. When the procedure will take place
- B. Who will perform the procedure
- C. Where the procedure will be performed
- D. What will happen during the procedure
Correct Answer: D
Rationale: Describing what will happen reduces fear of the unknown.
Which suggestion is most appropriate for the nurse to offer the parents in this situation?
- A. Avoid controlling the child.
- B. Praise accomplishments as deserved.
- C. Avoid discussing peer comments.
- D. Show disapproval of negative labels.
Correct Answer: B
Rationale: Praising accomplishments boosts self-esteem and counters ridicule.
What is the best suggestion the nurse can give the nursing assistant caring for the 2-year-old child at this time?
- A. Let the child choose from two acceptable alternatives.
- B. Withhold something the child desires until the child complies.
- C. Identify what is expected of the child, rather than ask.
- D. Inform the mother if the child continues to be uncooperative.
Correct Answer: A
Rationale: Offering choices fosters autonomy while maintaining boundaries.
Which assessment findings are most characteristic of a 10-month-old infant with the diagnosis of failure to thrive?
- A. The infant cries vigorously when handled.
- B. The infant has a delay in developmental milestones.
- C. The infant appears pale and lethargic.
- D. The infant's sucking and grasp reflexes
- E. The infant has delayed understanding of speech.
Correct Answer: B,C,E
Rationale: Delayed milestones, pallor, lethargy, and speech delays are hallmark signs of failure to thrive.
When the parents ask if their child is psychotic, the nurse who is performing the initial interview is most correct in explaining which of the following as a behavior exhibited by psychotic people?
- A. They have poor response to new situations.
- B. They have difficulty in relationships.
- C. They cannot differentiate reality from unreality.
- D. They feel helpless in resolving problems.
Correct Answer: C
Rationale: Psychosis is characterized by impaired reality testing.