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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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If the teenage mother expresses feeling inexperienced and inadequate in caring for the baby, which referral is best?
- A. Project Head Start
- B. Planned Parenthood
- C. Parent-Teacher Association
- D. Parenting classes
Correct Answer: D
Rationale: Parenting classes provide education and support to build confidence and skills.
If the adolescent benefits from therapy that focuses on growing up in an alcoholic household, the nurse is most likely to observe the adolescent developing an ability to do what?
- A. Keep promises
- B. Trust others
- C. Solve problems
- D. Honor commitments
Correct Answer: B
Rationale: Trust is a key area of growth for those from alcoholic households.
Which assessment finding would lead the nurse to suspect physical abuse?
- A. The child protests when approached by the nurse.
- B. The child has patchy loss of hair.
- C. The child has a fresh bruise on the forehead.
- D. The child has an abrasion on the right knee.
Correct Answer: C
Rationale: A fresh bruise in an unusual location raises suspicion of abuse.
Which nursing goal is the highest priority at this time?
- A. To improve the client's distorted body image
- B. To help the client use healthier coping techniques
- C. To restore normal nutrition and health
- D. To help the client develop assertiveness
Correct Answer: C
Rationale: Restoring nutrition is critical to address life-threatening malnutrition.
Which nursing action is most appropriate for the mother at this time?
- A. Briefly take over bathing the newborn.
- B. Advise the mother to discontinue the bath.
- C. Give all future baths in the nursery.
- D. Point out the good job being done.
Correct Answer: A
Rationale: Taking over briefly supports the mother, reducing her anxiety while allowing her to remain involved.