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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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Which information is most appropriate for the nurse to collect at this time?
- A. The infant's weight and length
- B. The infant's breath and heart sounds
- C. The infant's head and chest circumference
- D. The infant's sucking and grasp reflexes
Correct Answer: A
Rationale: Weight and length assess growth and potential failure to thrive, relevant to the mother's concern.
Which behavior best indicates that an adolescent is at increased risk for suicide?
- A. Disobeying family rules
- B. Arguing with siblings
- C. Letting his grade average drop from a 92 to 88
- D. Becoming depressed over a recent breakup with a girlfriend
Correct Answer: D
Rationale: Depression following a breakup is a significant risk factor for suicide.
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.
Which advice given to the preschooler's mother is most appropriate for relieving the 4-year-old child's anxiety?
- A. Give your child some new toys.
- B. Let your child stay up later at night.
- C. Invite the child's grandparents to visit.
- D. Spend more time alone with your child.
Correct Answer: D
Rationale: Quality time with the parent enhances the child's sense of security.
What information is most helpful for the nurse to obtain next?
- A. The mother's expectations of an infant's behavior
- B. If the mother plans to finish high school
- C. The kinds of toys the mother has for the baby
- D. None of the above
Correct Answer: A
Rationale: Understanding the mother's expectations helps identify misconceptions contributing to the concern.