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If the nurse's suspicions are true, which assessment findings require further investigation?
- A. The child demonstrates sexual activity with a doll.
- B. The child has a gonorrheal infection.
- C. The child is underweight for the corresponding height.
- D. The child complains of burning during urination.
- E. The child is afraid to be left alone with the suspected nurse.
- F. The child has trouble sleeping through the night.
Correct Answer: A,B,D
Rationale: Sexual behavior, gonorrhea, and urinary symptoms are strong indicators of sexual abuse.
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Which statement is the best explanation for the adolescent's behavior?
- A. Aggression is a common behavior manifested by cognitively disabled people.
- B. Aggression is a response that occurs when a person feels frustrated or frightened.
- C. Aggression is an indication that the client has a poor opinion of the care provided.
- D. Aggression is a common way for adolescents to communicate they are experiencing pain.
Correct Answer: B
Rationale: Frustration or fear often triggers aggression in cognitively disabled individuals.
Which nursing strategy is best to help the child overcome the fear of being in the unfamiliar hospital environment?
- A. Bringing a favorite blanket from home
- B. Providing age-specific toys such as a stuffed animal
- C. Having one or both parents nearby at all times
- D. Placing the child in a room with a same-aged child
Correct Answer: C
Rationale: Parental presence provides the most comfort and security for a young child.
When discussing the home environment with the parents, the nurse should explain that which one of the following is the most appropriate environment for an autistic child?
- A. Stimulating, with a variety of sensory experiences
- B. Consistent, with a minimum of physical change
- C. Flexible, with the freedom to initiate activity
- D. Strict, with narrow limits for acceptable behavior
Correct Answer: B
Rationale: Consistency minimizes anxiety and supports routine.
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.
Which of the following risk factors would the nurse expect to note when assessing the mother?
- A. The pregnancy was unplanned and unwanted.
- B. The baby's father abandoned the mother.
- C. The mother is an adolescent.
- D. The mother's socioeconomic status is low.
- E. The mother has a history of alcohol and drug abuse.
- F. The mother has dropped out of high school.
Correct Answer: A,C,D,E
Rationale: Unplanned pregnancy, adolescent motherhood, low socioeconomic status, and substance abuse are risk factors for failure to thrive.