Nokea
If the adolescent who is involved in gang activities demonstrates the following behaviors during group meetings, which is most indicative of resistance to therapy?
- A. The adolescent borrows cigarettes from others.
- B. The adolescent laughs inappropriately.
- C. The adolescent keeps checking the clock.
- D. The adolescent fidgets in the chair.
Correct Answer: B
Rationale: Inappropriate laughter suggests discomfort or dismissal of the therapeutic process.
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Which warning signs of suicide should the nurse include?
- A. Withdrawal
- B. Apathy
- C. Angry outbursts
- D. Lower standardized test scores in reading and math
- E. Delusions
- F. Incoherent speech
Correct Answer: A,B,C
Rationale: Withdrawal, apathy, and angry outbursts are common suicide warning signs.
Which nursing action is most appropriate in this situation?
- A. Asking the client why he or she is so suspicious
- B. Putting the chart away
- C. Handing the client the form to read
- D. Telling the client that it is illegal to read the client record
Correct Answer: B
Rationale: Putting the chart away maintains privacy without escalating suspicion.
When the parents ask about the side effects of taking methylphenidate hydrochloride (Ritalin), the nurse correctly explains that the child may have which common cluster of signs and symptoms?
- A. Nausea, vomiting, and diarrhea
- B. Fatigue, drowsiness, and dry mouth
- C. Insomnia, tachycardia, and anorexia
- D. Hypotension, bradycardia, and constipation
Correct Answer: C
Rationale: Insomnia, tachycardia, and anorexia are common side effects of Ritalin.
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.
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.